Health Information Exchange

From Clinfowiki
Jump to: navigation, search


Health Information Exchange refers to the electronic sharing of patient health records between providers; the term is also often used to refer to organizations providing the technology platform or service to enable this electronic sharing functionality[1][2].

Electronic health information exchange (HIE) allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically—improving the speed, quality, safety and cost of patient care.[1]


Appropriate, timely sharing of vital patient information is key component of HIE. It will help in decision making and allow provider to improve patient care. HIE helps coordinate patient care, reduce duplicate test and treatment, improve quality of care and safety, allow consumer in their care, facilitate public health reporting and public health.


The totality of a patients’ medical history has been recognized as a major source of inefficiency and a barrier to delivery of quality medical care[3]. Medical records in the electronic medical record often exists in disparate silos (offices, hospitals, clinics, etc.) making it difficult for clinicians to obtain complete data when caring for a patient. This is especially true when the patient receives care in separate locations from various providers. To address this problem, health information exchanges (HIE) have been developing based on several standards and technologies.

The process of health information exchange has been described as the data following the patient. It is a data-sharing model where the longitudinal health information for a particular patient can be accessed or referenced from an electronic source. This data can then be shared securely with an entity that has access to the data.

Driving this effort is an initiative by a collaboration of health care professionals and industry to improve the way computer systems in healthcare share information. This non profit collaboration is known as Integrating the Healthcare Enterprise (IHE). Through the development and publication of “integration profiles”, IHE has defined the standard processes and technologies needed to support an HIE framework[4]. Using common web technologies the data in an HIE is typically transmitted electronically in standard formats for the purpose of storage and retrieval.

HIE & Meaningful Use

With the development of an EHR incentive program, the CMS defined standards and criteria for incentive payments. These standards, meaningful use, not only promotes use of electronic health records, but also aims to improve health through the use of EHRs.

Meaningful Use Stage 2 particularly emphasizes health information exchange forward as it requires the exchange of an extensive array of data at points of care transition and discharge. Additionally, this data needs to not only be made available to the patient, but it must be uniformly formatted, requiring considerable interoperability among different vendors and platforms.

Meaningful Use Stage 2 focuses on providing a summary of care when a patient is transitioning from one place of care to another. There are three Measures involved in this process to meet Stage 2 Requirements for Meaningful Use.

Measure 1: Provide a summary of care record for more than 50% of transitions of care and referrals.

Measure 2: Provide a summary of care for more than 10% of the total number of transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via an eHealth Exchange participant.

Measure 3: EPs must also satisfy one of the following criteria: a. Conduct one or more successful electronic exchanges of a summary of care with a recipient who has EHR technology that was developed/designed by a different EHR technology developer than the sender's EHR technology b. Conduct one or more successful tests with the CMS designated test EHR during the EHR reporting period.

This focus on successful exchanges of summary of care is vital to Health Information Exchange as this will address patients leaving one facility and being admitted to another facility without the necessary paperwork. Many times in Health care data, and information is lost as a patient moves from one facility to a next. There are many benefits to the electronic transfer of Summary of Care: 1. Allows provider to receive critical health data at transfer of care. 2. Improves speed and accuracy of data absorption into the new EHR. 3. It eliminates duplicate ordering of labs and blood work.

The Document

Extensible Markup Language (XML) is a standard markup language used in web technology and other computing platforms. XML is the language used to encode patient data that is transmitted within the framework of a health information exchange. The encoded information is referred as a “document”. The document includes text for human readability as well several vocabulary standards such as SNOMED and LOINC for machine readable, structured data. In this way the document can be consumed by an electronic health record or simply rendered by a web browser that is XML capable.

Two standards exist for the structural specification of the XML document. The first is a lean version of critical patient data called a continuity of care record (CCR). This is an American Society for Testing and Materials (ASTM) standard and its purpose was to encode a small set of common patient data such as demographics, medications, allergies and problems[5]. The second standard is a derivation of HL7’s common document architecture (CDA) format called the continuity of care document (CCD). This standard is based on CCR structure but adds more complexiy and has been designed to carry more data elements than the CCR. Although many have looked at these as competing standards, it is more accurate to say they are complementary[6]. The XML document is typically produced by an electronic health record (EMR) from a physician’s office, hospital or a personal health record. The CCD or CCR are the primary document structures in an HIE.

The Infrastructure

Once the document is generated it needs to be transmitted, stored, and then made available for an authorized user to "consume" the document. HIEs use web technologies such as TCP/IP for transport between destinations. There are many vendors in health care who provide HIE infrastructure. This infrastructure closely adheres to the standard profiles set by IHE. The infrastructure has multiple components but most notably includes:

  • Cross enterprise document sharing (XDS) repository(s). These act as repositories to store the documents and can be centralized or federated.
  • Cross enterprise document sharing registry(s) keep the metadata for each document. In this way a document can be located by querying the registry which links to the actual document in a repository.
  • The cross community gateway (XCA) is the profile describing a connection between different HIE environments. Connecting HIEs though XCA technology allows a query to cross into other "connected" HIEs and retrieve patient information located in disparate repositories. In this way several HIEs can deliver federated information about a single patient.
  • The patient identity cross-reference (PIX) or patient demographics query (PDQ) managers are program specifications that define the way a patient is identified in a registry. First and foremost in any HIE, proper patient identification is paramount to accuracy. The difficulty is that HIEs store documents belonging to one patient but generated from various entities such as hospitals or clinics. Each entity may not be working with a common patient identifier. Therefore a query needs to match the patient with the correct document using demographic information rather than a master patient index (MPI). The PIX or PDQ profiles, are 2 methods for cross-referencing the patient identity attributes.
  • External data representation (XDR) and XML document management (XDM) specifications are transported over SMTP for direct messaging, which is an effort of the DIRECT Project.

Types of HIE

Directed Exchange

Directed exchange is the exchange of information between care providers in support of coordinated care. Directed exchange allows providers to securely and reliably send information such as discharge summaries or lab results to other providers, ensuring effective coordination of care. This form of health information exchange is also used to send immunization data to public health organizations as well as for reporting quality measures to the CMS.

Query-based Exchange

Query-based exchange allows a provider to query information on a patient from another provider. Query-based exchange is particularly in critical in unplanned care, when a provider may need to seek pertinent information such as the patient’s medications or history.

Consumer-Mediated Exchange

Unlike directed exchange and query-based exchange, consumer-mediated exchange allows patients to consolidate and moderate access to their health information among providers. Placing health information in the hands of patients allows them to not only better manage and track their health and health information, but also allows them to be an integral part of coordination of care, correct wrong or missing information, correct billing information.

Securing Information

No discussion of patient data exchange is complete without mentioning security. The audit trail and node authentication (ATNA) profile from IHE addresses many dimensions of privacy and security[7]. It requires data to by encrypted and also outlines a standard for authentication and authorization of data access. Data access and audit trails for reporting each transaction are also outlined in this profile.

Challenges of HIE

HIE is viable part of health system. It will help to track of patient's progress of chronic condition and improve patient outcome. Existence of multiple payers, provider, organization, different EHR system will create challenges to implementation of HIE. Most common challenges are[2]:

  • HIEs must make wise selection of one or more vendors to deliver services successfully.

There are many vendors available in market and having competition. HIE vendor’s selection must meet institutes requirement and provide sufficient support. Selection of HIE also in budget of institute. Poor selection will face tremendous loss of asset and push back from users.

  • Lack of standards and interoperability.

As of now, more than thousand EHR systems exist in market. Few systems lead US market but small institutes do not afford leading EHR and relies on affordable EHR[3]. There is lack of standards and interoperability lead difficult to implement HIE in to existing EHRs.

  • Multi-vendor vs single-sourced HIE option.

No one vendor dominates the market with all the requisite skills and solutions needed to supply solutions to HIEs. Different vendor has mastery in different technology and interoperability is poor between two technologies. Sometime one vender has sub-contract with other vender. Implementing 2 HIE in one institute also cost consuming and require multiple training to end users.

  • Integration costs to existing EHR systems complex and underestimated.

Due to multiple EHRs, lack of interoperability and lack of IT resources take longer time and partial integration of multiple EHRs system. HIEs will help patient care. But there is always question, who will pay for it?

  • Complexity of 'data sharing agreements' process.

Data sharing agreement between two parties is easy but adding more parties, and the time to complete a cohesive DURSA agreement across all HIE use cases can be lengthy as well as costly.

  • HIEs data creating conflicts in 'Quality care incentives' model.

Value base purchase and ACO require separate data sharing and quality care initiatives with their respective payers. HIEs will discover additional data sharing between those hospitals in ACO as competing for the same resources.

  • Lack of viable financial model to support HIEs.

Without viable funding source, all HIEs will fall apart. It will improve patient care and outcome but it will take a time to see benefit. There is competition between insurance company and lack of universal insurance. Patients or employer continues changing insurance company. Who will pay for HIE?

  • Successful integration of HIE in current provider's work flow.

Adding any additional step will change work flow. Better technology and solid use cases, higher utilization and adoption by end users. If HIEs will not see as value added step then higher chance of push back from users.

  • HIE bring mass of information and analysis is time and cost consuming.

Time is money and adding single step will utilize that time. HIEs will bring mass of information from different clinical system. It is hard to manually analysis of all information. It will reduce providers production or increase provider burn out.

  • Technology for HIEs is still fragmented. Different vendors provide different architecture and data components.

There is not a single platform which provide all information.

Related papers


  1. Health information exchange. (2015, November 2). In Wikipedia, The Free Encyclopedia. Retrieved 22:14, November 27, 2015, from
  2. What is HIE? (2014, May 12). In Retrieved November 27, 2015, from
  3. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2002). To err is human: building a safer health system. National Academy of Science, Institute of Medicine.
  4. Spronk, R. (2012). IHE: an implementation framework based on messaging standards. Retrieved from Ringholm bv website:
  5. (2010) E2369-05 Standard Specification for Continuity of Care Record (CCR). Retrieved November 19, 2010, from
  6. David Kibbe. (2010) Untangling the electronic health date exchange. In The Healthcare Blog. Retrieved November 19, 2010, from
  7. Audit trail and node authentication. (2015, 26 February). In IHE Wiki. Retrieved 23:17, November 27, 2015, from

full-text. things you should know about HIEs_FY15 HIE Committee_FINAL.pdf