11/6/2021

Princess Sumaya University for Technology

The King Hussein School for Computing Sciences

Course 13768: Health information systems

Topic 4: Data Standards and Exchange

Dr. Rafat Hammad

Acknowledgements: Most of these slides have been prepared by Robert Hoyt, Elmer V Bernstam, and William Hersh
and adopted for our course. Additional slides have been
1 added from the mentioned references in the syllabus

Learning Objectives

After viewing the presentation, viewers should be able to:

∗ Explain the importance of standards and interoperability for
health and biomedical data
∗ Discuss the major issues related to identifier standards, including
the debate on patient identifiers
∗ Describe the various message exchange standards, their explicit
roles, and the type of data they exchange
∗ Discuss the different terminology systems used in biomedicine
and their origins, content, and limitations

1
 11/6/2021

Learning Objectives (cont.)

After viewing the presentation, viewers should be able to:

∗ Identify the need for and benefits of health information
exchange (HIE) and interoperability
∗ List healthcare data that should be shared
∗ Enumerate HIE challenges and barriers
∗ Describe several organizations known as Health Information
Organizations (HIOs)
∗ Summarize the newest HIE models

Introduction

∗ Data standards promote consistent naming of individuals,

events, diagnoses, treatments, and everything else that takes
place in healthcare
∗ Standards enhance the ability to transfer data among
applications, thus leading to better system integration
∗ Standards also facilitate interoperability among information
systems and users

2
 11/6/2021

Definition

∗ According to the International Standards Organization, a

standard comes from “a standard document established by
consensus and approved by a recognized body that provides
for common and repeated use, rules, guidelines or
characteristics for activities or their results, aimed at the
optimum degree of order in a given context.” (ISO/IEC Guide 2
2004)

Interoperability

∗ Standards facilitate an important process known as

interoperability
∗ The Institute for Electronic and Electrical Engineers (IEEE)
updates its definition of interoperability regularly and its 2016
definition is “the ability of a system or product to work with
other systems or products without special effort on the part of
the customer. Interoperability is made possible by the
implementation of standards.”

3
 11/6/2021

Interoperability

∗ Walker 2005 has described levels of interoperability:

• Level 1 – no interoperability, e.g., mail, fax, phone, etc.
• Level 2 – machine-transportable (structural); information cannot be
manipulated, e.g., scanned document, image, PDF
• Level 3 – machine-organizable (syntactic); sender and receiver must
understand vocabulary, e.g., email, files in proprietary format
• Level 4 – machine-interpretable (semantic); structured messages
with standardized and coded data, e.g., coded results from
structured notes, lab, problem list, etc.

Interoperability Roadmap

4
 11/6/2021

Value and Limitations

∗ Standards in many industries are critical, e.g., standards for

railroad cars enabled different railroads to be built out around
various countries, all adhering to a standard of the wheels
being a certain distance apart
∗ But there are limitations to standards, e.g., the standards for
operating systems that emerged from Microsoft in the latter
part of the 20th century - Microsoft Windows and Office – have
benefits of widespread use but also limitations as well

Standards Development

∗ The stages for the development of standards is as follows

according to Hammond 2014:
• Identification
• Conceptualization
• Discussion
• Specification
• Early implementation
• Conformance
• Certification

5
 11/6/2021

Types of Standards

∗ Identifier standards
∗ Transaction standards
∗ Messaging standards
∗ Imaging standards
∗ Terminology standards

Identifier Standards

∗ Patient Identifiers
∗ Benefits are easy linkage of records but
can also compromise privacy and
confidentiality for the patient
∗ Reduce the problems of both duplicate
and overlaid records
• A duplicate record occurs when more than
one record exists for a patient, whereas an
overlaid record takes place when more
than one patient is mapped to the same
record.

6
 11/6/2021

Identifier Standards

∗ Patient identifier key attributes (Connecting for

Health 200%)
• Unique – only one person has an identifier
• Non-disclosing – discloses no personal information
• Permanent – will never be re-used
• Ubiquitous – everyone has one
• Canonical – each person has only one
• Invariable – will not change over time

Identifier Standards

∗ Other Identifiers
∗ The National Provider Identifier (NPI), which is assigned to
all physicians in the US. The payor for Medicare in the US,
the Centers for Medicare and Medicaid Services (CMS),
will not process claims without use of the NPI
∗ Employers must have a standard Employer Identifier
Number (EIN). In addition, the Affordable Care Act
requires health plans to have either a Health Plan
Identifier (HPI) or an Other Entity Identifier (OEID) that is
an identifier for use in transactions

7
 11/6/2021

Transaction Standards

∗ There is a set of transaction standards for healthcare

called ASC X12N
• developed to encourage electronic commerce for health
claims, simplifying what was previously a situation of
over 400 different formats between insurance
companies and others for healthcare transactions
∗ HIPAA legislation mandated the use of the ASC X12N
standards for healthcare business electronic data
exchange under the guise of “administrative
simplification”

Transaction Standards

∗ The original version of ASC X12 was called 4010. This was
superseded by a new version that was released in 2012
called 5010. The major transactions in 5010 and their
identifier numbers include:
• Health claims and equivalent encounter information (837)
• Enrollment and disenrollment in a health plan (834)
• Eligibility for a health plan (request 270/response 271)
• Health care payment and remittance advice (835)
• Health plan premium payments (820)
• Health claim status (request 276/response 277)

8
 11/6/2021

Messaging Standards

∗ Message exchange standards focus on different types

of messages and different types of data
∗ HL7 is the organization that develops and supports
standards and is properly called HL7 International
∗ The name HL7 comes from the OSI 7-layer model of
network communications.

Messaging Standards

∗ Version 2 of HL7 is widely used throughout health

care
∗ HL7 Version 2 is mostly a syntax. This means that the
sender and the receiver must understand the
meaning of the messages
∗ Within HL7 Version 2, each message has segments,
and each of the segments has a three-character
identifier and then values that follow it

9
 11/6/2021

Messaging Standards

∗ HL7 Version 2 message ∗ Example of HL7 Version 2

message:
segments and identifiers:
• MSH|^~\&||^123457^Labs|||2008081
• MSH – message 41530||ORU^R01|123456789|P|2.4
header • PID|||123456^^^SMH^PI||MOUSE^
MICKEY||19620114|M|||14Disney
Rd^Disneyland^^^MM1 9DL
• EVN – event type • PV1|||5N|||||G123456^DR SMITH
• PID – patient • OBR|||54321|666777^CULTURE^LN||
|20080802||||||||SW^^^FOOT^RT|C9
identifier 87654
• OBX||CE|0^ORG|01|STAU||||||F
• OBR – results header • OBX||CE|500152^AMP|01||||R|||F
• OBX||CE|500155^SXT|01||||S|||F
• OBX – result details • OBX||CE|500162^CIP|01||||S|||F

Messaging Standards

∗ HL7 Version 3 is an attempt to introduce semantics

into messaging
∗ HL7 Version 3 is based on Reference Information
Model (RIM)
∗ The elements of the message defined in the context
of these abstract classes:
• Entity – things in world, e.g., people, organizations, other living
subjects, drugs, devices
• Role – capability or capacity, e.g., patient, practitioner
• Participation – role in context of an act, e.g., performer, target
• Act – clinical or administrative definitions, e.g., observation,
diagnosis, procedure
• Act relationship – links between acts, e.g., diagnosis act

10
 11/6/2021

Messaging Standards

∗ All clinical,
administrative,
financial, etc.
activities of
healthcare can
be expressed in
“constraints”
to the RIM.
An example of a pulse reading in a
physician’s office

Messaging Standards

∗ Fast Health Interoperability Resources (FHIR)

∗ With the widespread adoption of electronic health
records and other clinical data systems, a new robust
interoperability standard was needed.
∗ When FHIR emerged as the leading candidate for
interoperability, HL7 International took over its
development.

11
 11/6/2021

Messaging Standards

∗ A key component of FHIR is its Resources, which comprise the

content of its messages
∗ There are 6 types of resources:
(http://www.hl7.org/fhir/resourceguide.html ):
• Clinical: The content of a clinical record
• Identification: Supporting entities involved in the care process
• Workflow: Manage the healthcare process
• Financial: Resources that support the billing and payment parts of
FHIR
• Conformance: Resources use to manage specification, development
and testing of FHIR solutions
• Infrastructure: General functionality, and resources for internal FHIR
requirements

Messaging Standards

FHIR Resources

12
 11/6/2021

Other HL7 Standards

Clinical Document Architecture (CDA)

∗ Another important activity of HL7 is the Clinical Document
Architecture (CDA). CDA is important because most health
care information is in the form of documents, and these are
used to allow humans to read them.
∗ The current version of CDA, Version 2, has three levels of
interoperability
• Level 1 – general document specification
• Level 2 – adds document types with allowable structures
• Level 3 – adds mark-up expressible in structured form, such as
RIM

CDA

CDA Version 2

13
 11/6/2021

CDA

Document
Template Types

Imaging Standards

∗ We want to move image data from the devices that capture the
data into records so that they can be viewed, and then we may
want to archive them in various ways.
∗ The Digital Imaging and Communications (DICOM) standard is
intended for the transport of images.
∗ DICOM was developed by the American College of Radiology
and the National Electrical Manufacturers Association, and there
is a Web site devoted to its details ( http://dicom.nema.org/ ).

14
 11/6/2021

Imaging Standards

DICOM Standard

Device, Prescribing, and Laboratory

Standards

∗ The original standard for controlling and linking information

from medical devices was called the Medical Information Bus
(MIB). There is also an open source Integrated Clinical
Environment (OpenICE, https://www.openice.info/ )
∗ The National Council for Prescription Drug Programs’ (NCPDP,
www.ncpdp.com ) SCRIPT is the communications standard
between the prescriber and the pharmacy
∗ The EHR Laboratory Interoperability and Connectivity Standard
(ELINCS). ELINCS has been operationalized using HL7 Version
2.5.1. and covers the entire process of outpatient laboratory
usage

15
 11/6/2021

Patient Summary Standards

∗ Over a decade ago, the need to exchange patient summaries led to

the development of the Continuity of Care Record (CCR)
∗ The goal for the CCR was to be, “a set of basic patient information
consisting of the most relevant and timely facts about a patient's
condition” (ASTM International 2003)
∗ The original CCR standard, however, was not compatible with any
existing standards, and this led HL7 and several vendors to create
the Continuity of Care Document (CCD), which would be based on
HL7 Version 3, and the Clinical Document Architecture (CDA)

Patient Summary Standards

∗ Stage 2 of the Meaningful Use criteria set forth the required data set for patient
summaries. The so-called required data set for the CCD includes:

Header Medications
Purpose Immunizations
Problems Medical equipment
Procedures Vital signs
Family history Functional status
Social history Results
Payers Encounters
Advance directives Plan of care
Alerts

16
 11/6/2021

Messaging Standard Platforms

∗ Today’s EHRs are large, monolithic systems and not platforms on

top of which other applications and innovations can be built
∗ Mandl et al. have developed the Substitutable Medical Apps
Reusable Technologies (SMART) platform, based on the idea that
there should be an underlying platform upon which “apps” can
built that access a common store of data and functions (Mandl
2012)
∗ SMART has also adapted FHIR as its API for accessing data, hence
the phrase SMART on FHIR. It has been implemented for EHRs and
extended to areas like genomics and precision medicine
applications (Mandl 2016) (Alterovitz 2015)

Terminology Standards

∗ The benefits of computerization of clinical data depend upon

its “normalization” to a consistent and reliable form so we can
carry out tasks such as aggregation of patient data, clinical
decision support, and clinical research
∗ But clinical language is also inherently vague, sometimes by
design, and that can be at odds with the precision of
computers
∗ Terminology standards are important for establishing reliable
terms for transfer and use of data through the computer

17
 11/6/2021

Terminology Standards

∗ There are a number of use cases for standardized terminology,

including (Chute 2005):
• Information capture – documenting findings, conditions, and
outcomes
• Communication – transferring information
• Knowledge organization – classification of diseases, treatments,
etc.
• Information retrieval – accessing knowledge-based information
• Decision support – implementing decision support rules

International Classification of
Diseases (ICD)

∗ The World Health Organization (WHO) publishes the ICD

classification system to collect data worldwide on the causes
of morbidity and mortality
∗ ICD is updated annually but limitations on expansion of
certain categories of disease have traditionally required a
major revision of ICD approximately every ten years
∗ In the U.S., ICD is clinically modified (CM) because it is also
used for reimbursement
∗ Most of the world has used ICD-10 since 1990 and the US
started ICD-10 in 2015 and ICD-9 is still in some use

18
 11/6/2021

ICD-10

∗ Although hierarchy between ICD-9-CM and ICD-10-CM is

similar, the code structure is different and the number of
codes in 2013 is nearly 69,000 versus approximately 14,000 in
ICD-9-CM
∗ Additionally, the US had to develop a replacement for
Volume 3 of ICD-9-CM so hospital systems could report
procedures on inpatients, the procedural coding system, ICD-
10-PCS
∗ ICD-10-CM provides extensive expansion and significantly
more specification than ICD-9-CM (see next 2 slides)

ICD-9 vs ICD-10

19
 11/6/2021

ICD-10 PCS

∗ ICD-10-PCS is a completely different hierarchical structure than

volume 3 of ICD-9. PCS codes contain 7 alphanumeric
characters and are actually built based on tables rather than on
a tabular listing
∗ It uses digits 0-9 and letters A-H, J-N, P-Z. The first character is a
section (e.g. medical surgical). In the medical-surgical section:
the second is the body system, the third is the root operation
(standardized definitions), the fourth is the body part, the fifth
is the approach, the sixth is the device and the 7th is a qualifier

ICD-10

∗ There have been several informatics concerns about ICD-10-

CM
• One of these is the excess granularity as noted in the
comparison with ICD-9
• Many advocated that ICD-10 never be adopted, that it just be
skipped, and the US move from ICD-9-CM directly to ICD-11
• However, ICD-11 is not yet completed, and it would probably
be another two, maybe three, years before the development
of ICD-11-CM

20
 11/6/2021

Diagnosis Related Groups (DRGs)

∗ DRGs were originally developed to aggregate ICD-9

codes into groups that could be used for health
services research to look at hospital costs
∗ DRG codes tend to categorize multiple different types
of diseases that are in the same general body area
and require the same amount of resources
∗ All hospitalizations have been classified by their DRG,
and that influences the reimbursement that hospitals
receive for the hospitalization

Drug Terminology

∗ RxNorm is the recommended standard for medication

vocabulary for clinical drugs and drug delivery devices,
developed by the National Library of Medicine (NLM)
∗ RxNorm is the standard for e-prescribing and will support
Meaningful Use
∗ RxNorm encapsulates other drug coding systems, such as
National Drug Code (NDC)
∗ Example: 311642 (methylcellulose 10mg/ml ophthalmic
solution)

21
 11/6/2021

Digital Imaging and Communications

in Medicine (DICOM)

∗ DICOM was formed by the National Electrical Manufacturers

Association (NEMA) and the American College of Radiology
∗ While DICOM is a standard, vendors have modified it to suit
their proprietary applications, resulting in lack of true
interoperability
∗ DICOM supports a networked environment using TCP/IP
protocol (basic internet protocol) but is also applicable for
offline use

Logical Observations: Identifiers,

Names and Codes (LOINC)

∗ This is a standard for the electronic exchange of lab results

transmitted to hospitals, clinics and payers
∗ LOINC is divided into lab, clinical and HIPAA portions
∗ The lab results portion of LOINC includes chemistry,
hematology, serology, micro-biology and toxicology
∗ The clinical portion of LOINC includes vital signs, EKGs,
echocardiograms, gastro-intestinal endoscopy, hemodynamic
data and others
∗ The HIPAA portion is used for insurance claims

22
 11/6/2021

LOINC

∗ Other standards such as DICOM, SNOMED and MEDCIN have

cross references (mapping) to LOINC
∗ RELMA is a mapping assistant to assist mapping of local test
codes to LOINC codes
∗ The LOINC code for serum sodium is 2951-2; there would
be another code for urine sodium
∗ The formal LOINC name for this test is:
SODIUM:SCNC:PT:SER/PLAS:QN
(component:property:timing:specimen:scale)

Systematized Nomenclature of
Medicine: Clinical Terminology
(SNOMED-CT)

∗ SNOMED is the clinical terminology or medical vocabulary

commonly used in software applications, including EHRs
∗ SNOMED covers diseases, findings, procedures, drugs, etc.; a more
convenient way to index and retrieve medical information
∗ The vocabulary provides more clinical detail than ICD-9 and felt to be
more appropriate for EHRs
∗ SNOMED was required for stage 2 meaningful use to record family
history, smoking history, transitions of care, hospital lab submission
of reportable cases to public health agencies and submission of
cancer cases to cancer registries

23
 11/6/2021

Systematized Nomenclature of
Medicine: Clinical Terminology
(SNOMED-CT)

∗ This standard currently includes over 1,000,000 clinical

descriptions
∗ Terms are divided into 19 hierarchical categories
∗ The standard provides more detail by being able to state
condition A is due to condition B
∗ SNOMED concepts have descriptions and concept IDs
(number codes). Example: open fracture of radius
(concept ID 20354001 and description ID 34227016)

Systematized Nomenclature of
Medicine: Clinical Terminology
(SNOMED-CT)

∗ SNOMED links (maps) to LOINC and the International Classification

of Diseases (ICD) codes
∗ SNOMED is currently used in over 40 countries
∗ SNOMED-CT Example: Tuberculosis
∗ DE–14800
∗ . . . .
∗ . . . .
∗ . . . Tuberculosis
∗ . . Bacterial infections
∗ . E = Infectious or parasitic diseases
∗ D = disease or diagnosis

24
 11/6/2021

Unified Medical Language System

(UMLS)

∗ The development of the Unified Medical Language System (UMLS)

https://www.nlm.nih.gov/research/umls/ was launched by the NLM
in the late 1980s and was an attempt to reconcile the plethora of
vocabulary systems in health care
∗ There are three components of the UMLS:
• Metathesaurus – the thesaurus based on all the component
vocabularies of the UMLS, described in more detail below
• Semantic Network – maps generic relationships between the
semantic types of the concepts that are in the Metathesaurus, such
diseases and treatments
• Specialist Lexicon – collection of words and terms mainly designed to
assist in natural language processing applications

Health Information Exchange

25
 11/6/2021

Important Definitions

∗ Health Information Exchange (HIE) is the “electronic

movement of health-related information among
organizations according to nationally recognized
standards”
∗ Health Information Organization (HIO) is “an
organization that oversees and governs the exchange
of health-related information among organizations
according to nationally recognized standards”

Important Definitions

∗ Regional Health Information Organization (RHIO) is “a health

information organization that brings together health care
stakeholders within a defined geographic area and governs
health information exchange among them for the purpose of
improving health and care in that community.”
∗ Interoperability is defined as “the ability of two or more
systems or components to exchange information and to use
the information that has been exchanged”. This implies that
the data is computable and that standards exist that permit
interoperability

26
 11/6/2021

Interoperability Levels

∗ Foundational: refers to the technology or platform

used to exchange information
∗ Syntactic: means messages have a structure and
syntax that is understandable. Uses XML and HL7
standards
∗ Semantic: terminology and coding must be the same
for the sending and receiving organizations

Introduction

∗ Exchange (sharing) of health information is vital for

healthcare reform at the local, state and national level
∗ The next two slides will demonstrate the types of
healthcare data that should be shared
∗ If electronic health records don’t share data, then we
have moved from paper siloes of information to
electronic siloes; not the goal of anyone
∗ HIE is part of the Meaningful Use program, discussed in
the module on electronic health records

27
 11/6/2021

Healthcare Data Potentially Shared

∗ Clinical results: Lab, pathology, medication , allergies,

immunizations and microbiology data
∗ Images: Actual images and radiology reports
∗ Documents: Office notes, discharge notes and emergency
room notes
∗ Clinical summaries: Continuity of Care Documents (CCDs);
XML-based documents that standardize and summarize care
∗ Financial information: Claims data and eligibility checks
∗ Medication data: Electronic prescriptions, formulary status,
and prescription history

Healthcare Data Potentially Shared

∗ Performance data: Quality measures like blood

pressure or diabetes control, cholesterol levels, etc.
∗ Case management: Management of the underserved
and emergency room utilization
∗ Public health data: Infectious diseases outbreak data,
immunization records
∗ Referral management: Management of referrals to
specialists

28
 11/6/2021

Introduction

∗ Note that the term RHIO is inexact because HIOs do

not have to be regional; they can include only one city
or an entire state
∗ Furthermore, HIOs are being created for specific
populations such as those on Medicaid or the
uninsured
∗ We will use HIO when addressing health information
organizations (noun) and HIE to describe the act of
moving or exchanging (verb) health information

Nationwide Health Information

Network (NwHIN)

∗ The US federal government had the vision of creating a

nationwide sharing of healthcare information; for patients
who travel, military members and to provide sharing with
government agencies
∗ NwHIN is not a specific network but instead a set of policies
and standards that permit secure information sharing
∗ We will not present the history as outlined in the textbook
but summarize by saying that the NwHIN has a select number
of members who exchange some information but there has
been limited growth. The schema is outlined in the following
slide

29
 11/6/2021

NwHIN Schema

NwHIN

∗ The reality is that HIE is expensive to create and maintain and the
interest in national sharing is limited
∗ For that reason the federal government funded a state level HIE
program we will discuss later and they also created a simple
secure messaging (email) service to help with Meaningful Use
because many hospital and healthcare systems refused to share
(more in other slides)
∗ In 2012 NwHIN was renamed to the eHealth Exchange and
became managed by HealtheWay, a government and private
consortium. Later the same year, the initiative was renamed the
Sequoia Project

30
 11/6/2021

Sequoia Project Components

∗ eHealth Exchange: group of federal and private

organizations that share data
∗ Carequality: trust framework to connect current and
future healthcare data sharing networks
∗ RSNA Image Share Validation: tests vendor
compliance for exchange of medical images

Direct Project

∗ With the slow adoption of HIE nationwide an alternative plan

had to be developed for Meaningful Use
∗ The Direct Project involves secure messaging (email) between
clinicians, patients, hospitals, etc. Consults and discharge
summaries could be attached
∗ The Project requires all parties to apply and register for a
unique email. The project is administered by multiple health
information service providers (HISPs) that can be almost any
organization
∗ This is simply “push technology”, see next slide

31
 11/6/2021

Direct Project Schema

Direct Project

∗ Here is an example of a secure message address

b.wells@direct.aclinic.org
∗ The goal will be for EHR vendors to include this mechanism
within the EHR email system and not an external email
∗ Continuity of Care Documents (covered in the data standards
chapter) will be a standard way to summarize care and
attach to a secure email
∗ Patients will email their clinicians this way
∗ It is difficult to gauge the success of this program

32
 11/6/2021

Blue Button Project

∗ Another avenue to allow healthcare data sharing is to allow

patients to download their records and results using a
recognized “blue button” (see above icon)
∗ This approach was taken by the VA and other healthcare
organizations
∗ Blue Button Plus Project will use data standards such as the
CCD so downloads can be printed or shared and assist with
Meaningful Use requirements
∗ Meaningful Use mandates data sharing so HIOs can assist
(next two slides)

HIE and Stage 2 Meaningful Use

Provide patients the ability to view online, download, and transmit their health information
within 4 business days of the information being available to the EP

Provide patients the ability to view online, download, and transmit information about a
hospital admission

Provide clinical summaries for patients for each office visit.

The EP or EH who transitions their patient to another setting of care or provider of care or
refers their patient to another provider of care provides a summary of care record for each
transition of care or referral
Capability to submit electronic data to immunization registries or immunization information
systems
Capability to identify and report cancer cases to a public health central cancer registry

Capability to identify and report specific cases to a specialized registry (other than a cancer
registry)

33
 11/6/2021

HIE and Stage 2 Meaningful Use

Capability to submit electronic reportable laboratory results to public health agencies

Capability to submit electronic syndromic surveillance data to public health agencies

Record whether a patient 65 years or older has an advance directive

Imaging results consisting of the image itself and any explanation or other accompanying
information are accessible through Certified EHR Technology

Provide secure messaging

Stage 3 Meaningful Use and Beyond

∗ Read the textbook to learn more about stage 3

Meaningful Use and the Macra/MIPS program
∗ HIE will again be an important component, but with a
new administration and head of HHS it is too early to
know whether this program will continue or be
significantly modified

34
 11/6/2021

Health Information Organizations

(HIOs)

∗ HIOs have the potential to link together disparate healthcare

systems, offices, labs , etc. into one entity
∗ This permits “pull” technology, where for example, a
physician in Cincinnati can search for a patient and pull
discharge summaries and other results from a variety of
organizations
∗ The technology is the easy part. HIOs must be trusted and
deal with fiercely competitive organizations and they must
have a long term financial sustainability plan. This is much
harder than originally anticipated

Health Information Organizations

(HIOs)

∗ Many HIOs were started with early federal funds that are no
longer available
∗ HIOs can charge subscription or transaction fees but
healthcare organizations have to see value to be willing to pay
for this
∗ HIOs can support Meaningful Use and be HISPs
∗ There are some well known well run HIOs in the country, but
there have been many failures and stagnation
∗ Next slide will enumerate potential HIO functions

35
 11/6/2021

HIO Potential Functions

Functionality Functionality

Results delivery Quality reporting

Connectivity with EHRs
Clinical documentation
Alerts to clinicians
Electronic prescribing
Health summaries
Electronic referral processing
Consultation/referrals
Credentialing
Results distribution
Electronic health record (EHR) hosting
Assist data loads into EHRs
EHR interfaces
Drug-drug alerts
Drug-allergy alerts
Drug-food allergy alerts
Billing

Health Information Organizations

∗ At last survey (2013), there were about 200 HIOs in the US

but only a minority are mature and successful
∗ Many large hospitals/health care systems have decided to
create their own mini-HIOs to share only with clinicians and
offices in their network; thus thwarting the efforts of state
and federal HIE plans to exchange information broadly
∗ HIOs have many challenges outlined in another slide. Next
slide presents a successful example

36
 11/6/2021

HIO Facts

∗ Can be centralized or decentralized (federated)

∗ Can be for profit or not-for-profit
∗ Can be government, private or community based

Successful HIO Example

Case Study: The Health Collaborative (THC) (previously known as HealthBridge)

THC is a not-for-profit HIO serving the greater Cincinnati, Ohio, as well as parts of Kentucky
and Indiana that was founded in 1997.

• It has been quite successful financially with income not based on federal grants, but
rather on monthly subscription fees.

• Provides information exchange for 50 hospitals and 7500+ physicians.

• Provides access to imaging, fetal heart monitoring and hospital-based EHRs.

• They are a HISP and participate in the Direct Project.

• They also offer workflow redesign and disease registries, data analytics, HIE consulting,
quality reporting, public health reporting, syndromic surveillance, claims checks and
eligibility verification.

• Alerts for readmission, duplicative radiology, opioid prescriptions

37
 11/6/2021

Statewide Health Information Exchange

Cooperative Agreement Program (SHIECAP)

∗ The HITECH Act established funding for HIE within and across
state lines. Most states began the process in 2010
∗ Once again, the goal was to align with national HIT policy and
support Meaningful Use goals
∗ State organizations were supposed to fill gaps in sharing and to
fully embrace and possibly host Direct Project messaging
∗ The SHIECap program ended in 2011

HIE Barriers

∗ Lack of successful business models

∗ Environment is highly competitive
∗ Federal support monies are gone
∗ HIOs seem to work better in high population areas
∗ Return on investment (ROI) is unclear
∗ Proof of benefit is weak
∗ Privacy/Security issues

38
 11/6/2021

Newer HIE Models

∗ FHIR: covered in multiple other chapters. Will use the

FHIR data standard and RestFul APIs to request
information from remote and disparate systems. Not
standard of care, however
∗ Blockchain: same technology as used for Bitcoins. It is
a “distributed transaction ledger” that is difficult to
hack. Decentralized approach that is being tested in
healthcare

Newer HIE Models

∗ OpenHIE: open source initiative aimed at low to

middle income countries. Uses a service oriented
architecture (SOA)
∗ EHR Vendor-based HIE: vendors, such as Epic, have
options to share to physicians not in the network and
with those who are not using their EHR. Product is
known as Care Everywhere

39
 11/6/2021

Conclusions

∗ Standards are important for interoperability of healthcare data

and information.
∗ Identifier standards are important to identify people and
organizations in healthcare
∗ Individual patient identifiers are controversial, demonstrating
value and risk to linking individuals in information systems
∗ Messaging standards are important to move data and
information between information systems
∗ Terminology standards are important for normalizing the
representation of all concepts used in health information
systems

Conclusions (cont.)

∗ One of the major requirements for successful healthcare

reform is health information exchange—sharing of healthcare
electronic information between clinicians and between
clinicians and patients
∗ New Meaningful Use requirements will promote HIE with
tools such as patient portals and secure messaging
∗ Our highly competitive and fragmented healthcare system has
made sharing (HIE) among disparate organizations very
difficult

40