Viewpoints: May/June 2013
Watchful Waiting for Health Information Exchanges
In pharmacy school we learned about “watchful waiting” – the idea of monitoring a patient’s progress without giving him or her a pill, a shot, or a surgery, to see if symptoms improve on their own; then, if warranted, to stop watching and take action. However, few patients are content to “watch and wait” — most patients want the drugs, and they want them now! Some patients take the opposite approach and ignore the condition altogether. Watchful waiting is an active process.
As pharmacists it can be hard for us to get patients to watch and wait. But are we able to do as we say? I don’t know about you, but when I am sick I want a prescription to make it go away. What about when it comes to things like health information technology? Some of us are like the patient who wants it now — “Doctor, send me prescriptions electronically,” “Patient, use the automated phone service to call in your refills,” “Technician, use this iPad to help the patient find the right OTC product.” Some pharmacists, though, choose to ignore new technologies until they are forced to adopt them.
What about health information exchanges (HIEs)? If you’re like most pharmacists, it’s another abbreviation that you hear about at a pharmacy conference or in a publication like this one. HIMSS provides the following definitions of HIEs and some other related abbreviations, HIO and RHIO:
“An HIE provides access to and retrieval of patient information to authorized users in order to provide safe, efficient, effective and timely patient care.”
A health information organization (HIO) is a “formal organization formed to provide technology, governance and support for HIE efforts” at the state level.
A regional health information organization (RHIO) is a “formal organization formed to provide technology, governance and support for HIE efforts” at the regional level.
These concepts are not new, but the debate about HIEs has been renewed recently due to health care reform. We’ll look at some examples of HIEs, how they impact pharmacy, and the challenges that have kept most pharmacies away.
Examples of HIE Networks
The Delaware Health Information Network (DHIN) is considered to be the first live, statewide health information network. On the surface it appears that pharmacy is involved in this network; prescription data such as medication strength, quantity, prescriber information, and fill dates are shared for prescriptions filled at Walgreens, CVS, Rite Aid, Kroger, Safeway, and HEB. However, this data is being pulled from health plan or Medicaid claims history data, not from the pharmacies, and no data is being shared with the pharmacies. State Medicaid agencies outside of Delaware, mainly from contiguous states, are also contributing data to the DHIN.
In New York, Healthcare Information Xchange of New York (HIXNY) is an RHIO that includes physicians, hospitals, health plans, and healthcare associations. HIXNY appears to have taken the same approach as Delaware, obtaining the prescription data from the claims history, not from retail pharmacies. As of April 24, 2013, no retail pharmacies are on its list of data contributors, although HIXNY is exchanging information with hospital pharmacies. Two-way interoperable communication is available with EMRs and hospital information systems (HIS) including AthenaHealth, eClinicalWorks, GE Centricity, Greenway (inbound communication only), Healthcare Management Systems, Inc. (HMS), Medent, Data Strategies, Inc., and STI Computer Services, Inc.
More than 2.2 million patients are currently in the master index of HIXNY. Patients provide consent for organizations to view their records, which include demographics, diagnosis/complaint, allergies, inpatient medications, clinical encounters, laboratory results, image reports, patient consent, discharge summaries, and transcribed reports. Hospital pharmacists who have access to this information report how much this information helps them ensure proper patient care. But in all of the smiling testimonials, one face is missing — the retail pharmacist.
Pharmacies face several challenges to effectively engage in HIE’s, including cost, access to data, and interoperability. Despite advancements in HIE software, interoperability, security, and ease of access continue to pose challenges. While RHIOs like HIXNY allow for interoperability with a limited selection of EMRs, physicians who use other vendors may be left out. Those that have the benefit of using one of the selected EHRs to access the data still face the challenge of entering multiple applications to complete all of the tasks needed to use the shared data effectively.
For pharmacies to be able to participate, a pharmacy EHR will be needed. HL7, a recognized standard for health information exchange, has developed a functional profile for a pharmacy EHR. However, this would likely be a standalone piece of software that would bring in prescription history from the pharmacy dispensing system. This may be duplicative in areas where HIEs are already accessing prescription data from claims information. Also, there will need to be a way to share data from documented patient encounters (e.g. medication therapy management (MTM), vaccines) that have occurred at the pharmacy. To develop this functionality will cost pharmacy without a clear ROI for the investment.
Gathering Information for retail pharmacists to be active users, HIEs need to be open to retail pharmacist involvement but pharmacists also share in the responsibility. With the DHIN and HIXNY, retail pharmacies weren’t “needed” because the prescription information was obtained from claims data; however, if pharmacies were allowed to participate, they could benefit from the ability to access clinical information such as lab values and past medical history, to engage more effectively in clinical services such as medication therapy management (MTM), immunizations, and diabetes management.
We suggest applying watchful waiting to HIEs. Continue to monitor developments by keeping up to date with your national and state pharmacy organizations’ and software vendors’ efforts in this area. Look for opportunities to get involved in what they are doing, by attending meetings of the HIE and reading up on its activities. And be ready to take action. CT
Melissa Sherer Krause, Pharm.D., is a consultant with Pharmacy Healthcare Solutions, Inc., in Pittsburgh, Pa. She can be reached at email@example.com.
Electronic Health Record (EHR) Versus Electronic Medical Record (EMR)
EHR: An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
EMR: An electronic record of health-related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff within one healthcare organization. Source: National Alliance for Health Information Technology’s “Defining Key Health Information Technology Terms.” Report to Office of the National Coordinator for Heath Information Technology