Strategic Health Information Exchange Collaborative (SHIEC)

The Strategic Health Information Exchange Collaborative (SHIEC) is the national trade association of health information exchanges (HIEs). Its more than 51 HIE member organizations manage and provide for the secure digital exchange of health data for hospitals, healthcare providers and other participants serving more than half of the U.S. patient population. As the unbiased data trustees in their communities, SHIEC member organizations are critical to advancing effective, efficient healthcare delivery to improve health on a local, regional and national level.

In this HIE inPractice Feature, Dick Thompson, Executive Director and CEO of Quality Health Network and Board Chair of SHIEC, joins us to discuss the history of SHIEC, its current initiatives and challenges that the organization has overcome. He emphasizes the importance of learning from the collective experiences of HIEs in driving nationwide health data sharing.

Many of SHIEC’s HIE members, as well as its Strategic Business & Technology Partner members, are actively engaged in HIMSS. In fact, many of our HIE members were part of the founding volunteers who originally helped launch the HIMSS HIE content area and steering committee in 2006.

Partnering with HIMSS is a natural fit considering our shared interest in health IT and information exchange. In 2016, SHIEC became a HIMSS Non-Profit Organizational member, and more recently, SHIEC and HIMSS agreed to co-brand the 2018 Interoperability & HIE Symposium that will coincide with the 2018 HIMSS Conference & Exhibition to be held in Las Vegas March 5-9, 2018. HIMSS and SHIEC will co-host the event and collaborate on program development. 

We continue to look for opportunities that provide SHIEC members with broad access to thought leaders, vendors, regulators, and implementers working in health information technology. HIMSS remains an important partner in our mission and continues to be one of our most important resources.

We are still a very new organization, having begun in 2014. Our collaborative was created to help our members increase their economies of scale without losing their autonomy. We need to both strengthen our member’s ability to serve their local communities while strengthening the voice of our collective membership on the national stage. SHIEC exists to provide a forum for our members come together to learn from each other, to exchange ideas, solve problems, and create new high value opportunities. It is working. As an HIE-focused trade association, we have made a great deal of progress in a relatively short time. In June 2017, we welcomed our 50th HIE into the fold – doubling our membership from 2015. SHIEC’s current membership serves more than half of the U.S. population and many have been in the business of sharing data to improve care for more than a decade. We expect membership to grow to 75 HIEs within the next year. At that point, SHIEC member HIEs will provide data sharing and reporting services for most, if not all, of the U.S. population!

Additionally, because of feedback during our national conference held in the fall of 2016, we initiated a new membership category we call the SHIEC Strategic Business and Technology Partners (SB&T) program. This program helps our members more efficiently engage with our suppliers, industry consultants and other allied organizations so that together we can create more innovative and more cost effective solutions for the communities we serve. More than 29 SB&T partners collaborate regularly with our HIE members. 
Many have described the roles occupied by our HIE organizations in the multitude of communities we serve, but one that resonates with many of our members came from a comment by a physician user who said “I use my EHR to better care for my patients and I use my HIE to better care for my community.”

SHIEC members have learned to value the data sharing relationships that we have with our many EHR partners, because when we work closely together we make each other better.  HIEs are often viewed as “the trusted experts” when it comes to aggregating data and connecting disparate systems together (making them interoperable) within a community. Since HIEs are the “the trusted experts” connecting many disparate EHR systems together within communities/regions, how do we connect the HIEs together to create a national interoperable network of HIEs?

The pragmatic answers to that question began to emerge because of the 2015 SHIEC Leadership conference in Park City, UT – which became a watershed event for many SHIEC members. The initiative born from that gathering is known as the Patient Centered Data Home™ (PCDH) project.
 

The PCDH project is a straightforward interoperability project that connects multiple disparate HIE’s together in order to allow for the aggregation of data from any participating HIE into the HIE provider community providing care – whether at a “home HIE” or an “away HIE.”

At a high level, PCDH is a monitoring system based upon industry standards and practices that leverages the ability of HIEs to:

  • Gather data from multiple disparate sources in real time
  • Identify the individual the data is about
  • Identify the provider serving the individual or patient
  • Identify where the event occurred
  • Distribute that data in real time to those who need to know (e.g. the patient’s care team).

The PCDH architecture leverages the identity management and patient consent systems unique to each participating HIE while allowing for the rationalization of patient identities shared among the HIEs - without having a single “universal” identifier. PCDH uses industry standard push and pull (query) methods for data distribution and aggregations.

Many SHIEC HIEs have been successful in the real time collection and distribution of data from clinical events that occur from outpatient and/or inpatient facilities such as hospital admissions, discharges or transfers (ADTs). This means that when a patient presents for treatment, the healthcare provider system generates an ADT that can be used to automatically trigger alerts and Continuity of Care Document (CCD) data exchanges between care providers, even if the providers do not participate in the same HIE.

Our members wanted to implement a simple-yet-elegant approach for exchanging patient information across different HIEs and service areas. A participating HIE defines a “data home” for patients in their geographic area using the patient’s home ZIP code. Using triggering episode alerts (ADTs), providers are notified of patient care events which may occur outside of the patient’s “data home” and confirm the availability and specific location of the clinical data for both “home” and “away” HIEs. This enables either automated or manual query to access information – in real time – across state and regional lines as well as across providers within the care continuum. 

In the pilot program, the original participating HIEs served as nodes for sending and receiving patient information. As other HIEs were added, they were connected to one of the nodes, creating a mini hub. The national expansion creates a national network with data flowing through these hubs, similar to how banking systems route transactions. The result will mean that a patient from Baltimore could be treated in a hospital in San Diego that could exchange patient information with the patient’s home HIE, but the data may pass through one or more HIE hubs along the way.

In 2016, PCDH pilots were launched among 15 HIEs in three disparate regions – a Western Region (Utah, Arizona, western Colorado), Central Region (Oklahoma and Arkansas), and Heartland Region (Michigan, Indiana, Ohio, Kentucky, Tennessee). The initial PCDH pilots supported a total population of about 34 million, and since the PCDH initiative began, over 1.5 million alerts have been exchanged. Since the initial launch, an additional five (5) HIEs are now “live” and 11 more have pledged to join implementation efforts soon.

The pilot programs demonstrated that this system of exchanging information allows patients’ information to wrap around them – whether their travel be for traditional tourism purposes or for “medical tourism” purposes. PCDH can successfully provide real-time information and meet all state laws and local requirements.

We have chosen to make the PCDH initiative a priority because nationally we have a very mobile population; we believe that a patient’s health information should follow the patient wherever the patient receives care. In addition, this innovation does not require new technology or organization.
 

The HITECH Act had a dramatic impact on the entire health IT industry. Health IT transitioned from being a luxury for forward-looking clinicians to a reality for most. Widespread electronic health record (EHR) adoption and use became the norm for eligible clinicians under Meaningful Use (MU), and we now see the expectation that providers will share patient records with each other to support care transitions and chronic care management, whether across the city, within their regional community or across the country.
 
SHIEC member organizations have played a valuable role as the neutral community data trustee that can link different EHR systems and disparate healthcare systems and organizations through one connection. While SHIEC member organizations are by no means the only interoperability approach, we have continued to grow due to our stability and neutrality and our commitment to advancing health data sharing at local, regional and national levels.

Today, we see growing engagement of providers and other stakeholders in discussions around health information exchange beyond the EHR, they are expanding their focus to incorporate public health, long-term care and behavioral health as well as social determinant support services, emergency management, EMS, social services, criminal justice, community health centers, schools and others. Many of our HIEs are among the first in the country to incorporate many of these facets of healthcare into their interoperability approaches effectively.

In addition to supporting a broader definition of what types of data should be included in our data sharing efforts, SHIEC and its HIE members are actively moving toward business models that directly support our customers’ need to move to value-based payment models as outlined under MACRA. Our HIEs are creating and providing new services to support the future of value based care.

There are two major changes coming our way related to interoperability. 

First, the need for interoperability will only continue to grow in terms of scale. Second, it will grow in terms of new data and more data sources from many emerging stakeholders who are beginning to engage in exchange activities to support patient care. This includes the patient and their families, caregivers and consumers, especially with the continued growth of mobile health technologies.

Nobody will be surprised to hear that I expect the need for interoperability to grow for many years – and more likely for decades. There is an abundance of evidence illustrating that patient populations are mobile, and their health information must follow them regardless of where they are treated. To illustrate the point, the recent SHIEC PCDH pilot project that spanned seven HIEs in the Heartland project found that upwards of 57% of patients with records stored in the HIEs had records in two or more other HIEs simultaneously. This supports earlier industry studies that illustrated that patients utilize multiple healthcare provider systems to receive care. The need is growing, and we have a lot of work ahead to make it possible for clinicians and allied providers to share data with each other seamlessly and securely.

However, where things really get interesting is with the introduction of new data types that are important to providing care but are typically not yet included in interoperability and date exchange efforts. We are beginning to bring in data related to behavioral health, public health, research and other areas – types of data that have not yet been integrated into care delivery but that directly impact patient care. Many of our HIE members are at the forefront of integrating these types of information into care delivery. We have been developing technology, policies and procedures for integrating various types of health information while also paying careful attention to the various state and federal laws that govern different types of data. SHIEC really stands out in this area. Our member HIEs serve as a type of broker between the healthcare community, technology vendors, federal regulators as well as state and local regulators. Patient privacy and consent standards vary dramatically among states and communities, sometimes making it more difficult to share data for the benefit of patients.  Because our HIE members understand their own communities, are trusted and are held accountable by those community stakeholders and are well versed in the nuances for data sharing under which they must operate, they have created exchange mechanisms that work using many different technology solutions.  One size does not fit all – nor should it. 

This is important because we have been able to apply this practical neutrality to new areas now being tied into interoperability efforts. Many of our members have already successfully incorporated behavioral health, public health and social service organizations into their HIE ecosystem. SHIEC members are leading these interoperability efforts, demonstrated that it is possible, that it works and that it yields benefits.

SHIEC exists to promote dialogue, collaboration and create economies of scale. We do not believe that there is a single answer or a single way to broad-based interoperability and we firmly believe that we must collaborate with many others in order to serve our nation’s health and health care needs better. We will continue to pursue many new alliances and collaborations with a wide variety of public and private entities, which will advance interoperability use cases for the benefit of our collective stakeholders.
 
As a convener, we are bringing HIEs and our Strategic Business and Technology partners together to continuously share best practices, solve problems and learn more. As an advocate, we can speak with a strong voice to help educate our state and national leaders as to what needs to be done, what we can do today and what we hope to do tomorrow. 

I think we are just beginning to understand the many barriers that prevent success – some technical, some political, some human.  Most barriers can be overcome if we can work together even better. This caliber of work requires a higher level of trust. I am extremely pleased that the many different SHIEC members are working so well together to achieve a common goal - initially coming together to create SHIEC as a platform for improvement, and subsequently working towards a national interoperability platform (PCDH).

There will be many more challenges that we will overcome, but I have learned that the SHIEC members have a tremendous passion for what they do. They have terrific skills, great vision and they will execute well. 

What we have also learned within SHIEC is that all health and healthcare markets are local markets with distinct characteristics, issues and challenges. We truly understand that any potential interoperability solutions must address the needs, characteristics and challenges of the local ecosystem. People and process are as or perhaps even more important than technology. 

While one of the core values of the SHIEC organization is shared business practices and sustainability solutions, each of our member organizations operate in different environments. Thus, while we find significant value in sharing best practices and working collaboratively, we always must keep in mind our differences at the local level. Health information exchange is not “one size fits all” and as an organization we are well equipped to help our members learn from each other and to navigate the challenges of interoperability on both national and local levels. 

The biggest obstacle may be, in a word, variability. The HIE market is nuanced and constantly evolving, and there can be a dizzying number of players and use cases to consider. To make things even more complicated, every state, region or community within a region is slightly different regarding how things operate. Even for people who have been in the industry a long time and have solid relationships within their communities, it is a challenge to decipher what (or who) will work. 

The industry evolution toward value-based care and outcomes-based reimbursement is likely going to increase the variability in the short term. There are already a huge number of worthy projects and pilots underway, and there are many differences among them, which makes it hard to execute well. We are going to be integrating many new types of players (e.g. first responders, social services and public health) and many of these organizations do not use EHRs. We still need to be able to share data securely, and comply with applicable laws.
 
At SHIEC, our plan for mitigating these challenges is through collaboration and education. Our members have broad experiences and a strong willingness to share knowledge to support each other’s success. As an organization, SHIEC also has to keep our finger on the pulse of the technical and regulatory communities to make sure we’re constantly delivering the education our members need to stay informed and ahead of changes to the industry. 
 

I will reference a quote attributed to a former National Coordinator for Health IT, Karen deSalvo, M.D., who frequently said, “Information flows at the speed of trust.”  The technology of interoperability is important, but it is the trust between a sender and a receiver that enables interoperable exchange. SHIEC members are the custodians (the trustee) of the data being exchanged. We have been successful in our local markets by being the neutral data trustee that can allow health systems (even those that are fierce market competitors) to share information to better treat the patients we all serve. SHIEC members know that trust, like credibility, takes a long time to create. We all consistently strive to strengthen the trust we have created between our stakeholders and HIEs that allows the data to continue to flow. It is the foundation of trust has allowed SHIEC and our PCDH initiative to grow rapidly. It is essential to our long-term success.