• Missouri HC estimates HIE savings

    Limited knowledge of eHealth benefits relative to eHealth costs is long-standing deficiency. There are several partial estimates that offer some light on the subject, but partial means incomplete. A report from InterSystems, a health ICT supplier, Measuring ROI: Missouri Health Connection quantifies the benefits of an HIE doesn’t include a Return on Investment (ROI), as its title suggests. It’s an estimate of cost savings at Missouri Health Connection (MHC), relying mainly external cost estimates rather than estimates from MHC’s own costs.

    ROI’s a ratio of benefits to costs. There’s several ways to compile data needed to use the generic formula. Providing estimates of one part of the formula can be informative, but cannot be an ROI.

    Donaldson Brown, an engineer, invented ROI in 1914 when he was Assistant Treasurer at the Du Pont Powder Company, a multi-activity firm. It was the ratio of net earnings to the costs of operations. The methodology’s still used, and when applied to internal initiatives to improve performance, it’s a ratio of total benefits to total the costs of investment. Both costs and benefits can include extra cash and redeployed existing resources both over time.

    ED savings comprised 83% of the total estimated savings of almost US$12.9m. Clinical savings in the ED were 80% of the total, operational savings 20%. Total savings for all five categories were:

    Estimated Savings



    ED visits and costs



    OP medication errors



    IP medication errors



    Preventable readmissions



    Preventable litigation






    One MHC site using HIE has reduced ED blood specimens by 18%. It compares to studies claiming 56% fewer laboratory tests and a 36% drop in radiology examinations.

  • Is API making HIE obsolete?

    There are several eHNA reports on Health Information Exchange (HIE). One report asked When will HIE take off? Now, a report from Chilmark Research says HIE messaging-based and document-centric models helped healthcare organisations (HCO) coordinate resources and enhance services across networked clinician communities. It concludes that these HIE initiatives have reached their limits. Healthcare practices of assessing and mitigating population risks across distributed clinical care delivery networks needs far richer, diverse information flows that HIE can provide.

    Instead, Application Program Interface (API) offers a solution. It’s a set of commands, functions, protocols and objects that can be used to create software or interact with external systems. It provides developers with standard commands to perform common operations so they don’t have to write code from scratch.

    Chilmark Research’s 2014 report Migration to Clinician Network Management revealed a massive healthcare transformation outpacing the vendor community’s ability to keep up. This gap’s widened since then, partly because most products are tied to a specific approach, and also an obsolete technology stack that doesn’t take advantage of modern development and integration ideas. 

    There are increasing types of data supplying a wider range of applications. Social and behavioural data is being incorporated and provided to points of care and for risk profiling and predictive analytics. Patients reporting data from their wearables and devices are being gradually incorporated into product plans. Most vendors want to make this data available for new computing capabilities such as predictive modelling, machine learning, and cognitive computing.

    The new technical approach advocated by Chilmark’s to leave health data closer to where it’s created, and use API to make it available to diverse applications and users. The concept’s similar to a virtual database. It’s already used outside healthcare, and is a more effective way to supply and consume data. It’s a better way to accomplish development and integration goals too.

    Africa’s eHealth initiatives need to consider how to switch from HIE to API. The pace of change seems so wide and rapid that API may become obsolete before it’s exploited fully.

  • EHRs then HIE, or both at once?

    eHealth investment decisions are always tricky. Affordability determines how far health systems can go. In Africa, it’s always tight. Choosing EHRs may defer HIE decisions. Now, there’s an eHealth platform that offers both, Think!EHR.

    Health IT Central has a report that Tomaž Gornik, CEO of Marand, a Slovenia company, says “Postmodern EHR is the next stage in the development of EHRs”. It has a health data layer that connects all the apps and applications into one coherent system and it’s decoupled from applications, so independent of vendors. In this new health cyber-world, high-level interoperability’s paramount because all applications must capture, store, retrieve, analyse and use health data in a standardised, independent format.

    The report say Marand’s Think!EHR platform’s leading the way for health data platforms. It already has several major implementations already in use. One’s Moscow’s primary care eHealth system serving twelve million patients. Sweden and NHS England’s Open Source community are building a medication management solution on Think!EHR.

    It’s the first eHealth platform to combine Integrating the Healthcare Enterprise (IHE) document exchange standard with structured health data based on openEHR. It enables governments, healthcare providers, ecosystem enablers, vendors, Small and Medium-sized Enterprises (SME) and other healthcare providers to exchange and manage IHE and Health Level 7 (HL7) documents and simultaneously take advantage of fully structured health data.

    eHealth developments like this offer new possibilities for Africa’s health systems. They also require an investment strategy that expands eHealth skills to maximise the benefits.

  • HIE doesn't stand alone

    When eHealth resources are tight, it’s tempting to see components as discrete steps toward the receding golden uplands. Health Information Exchange’s (HIE) one example. As eHealth stretches outwards, HIE becomes increasingly important for information sharing, but it can’t stand alone.

    HIE Watch’s contributing writer Chris Nerney says there’s two dependencies needed to fulfil HIE’s potential. He says HIE depend on mHealth and cloud to capitalise on the opportunities to share medical information easily. It means that planned HIE investment needs to be part of a bigger, so more expensive, package to maximise its benefits. 

    This makes it a challenging decision for most African countries. At its simplest, the choices are invest in affordable HIE and achieve suboptimal returns, or invest in a combination of HIE, mHealth and cloud for optimal returns, but probably break the eHealth bank, so some other eHealth projects are deferred. Both decisions need a longer-term horizon and clarity about the scale of benefits available and the pace at which they can be realised. Nerney’s explicit. “Modern HIEs simply won’t accomplish their mission of health information exchange without embracing and leveraging modern information technologies.”

    Alongside these choices, there are security and privacy challenges too. Investment in preventative technologies and eHealth users skills and knowledge are vital, both increasing affordability challenges, but with a drag on benefits if they’re not in place. 

    Affordability challenges aren’t a reason for Africa’s health systems not to invest in HIE. Decision have to be put in the context of HIE’s timing for substantial information sharing for patient benefits and its affordability plan. It’s a set of tricky investment decisions coming over Africa’s horizon.

  • Finding HIE's benefits needs more work

    Sharing information between health professionals and their organisations is an important and large potential benefit of eHealth. The probability of realising it’s less clear. A team from the Department of Medical Informatics and Clinical Epidemiology at Oregon Health and Science University, the University of Washington in Seattle and the Veteran's Affairs Maine Healthcare System reviewed the performance of Health Information Exchange (HIE) identified in 34 outcome studies, mostly in the USA. Eight were from Europe, Canada, Israel, and South Korea. The studies also part of a report from the USA’s Agency for Healthcare Research and Quality (AHRQ) on HIE, and reported by eHNA.

    It found that the full impact of HIE on clinical outcomes and potential harms aren’t evaluated adequately. This is in a context where evidence supports other HIE benefits of HIE in reducing the use of specific resources and improving the healthcare quality. The finding’s important for Africa’s health systems with HIE plans.

    Writing in the Journal of Medical Internet Research (JMIR), the team says it identified 34 HIE outcome studies. None included clinical outcomes. Examples of the missing components are mortality and morbidity or identified harms. It did find low-quality evidence such as fewer duplicative laboratory and radiology tests, emergency department costs, hospital admissions, moderate benefits in fewer readmissions, better public health reporting, population outcomes, ambulatory healthcare quality, and disability claims processing. Most clinicians in the studies attributed to HIE positive changes in healthcare coordination, communication and knowledge about patients. 

    The team makes an important point about the challenges of evaluating HIE, which applies to most of eHealth: cause and effect is difficult to specify precisely. It says HIEs are intermediate to improving healthcare delivery. Its role’s to enable clinicians and other health workers better access to patient data to inform decisions, and facilitate appropriate testing and treatment. HIE isn’t specific to any health issue or diagnosis.

    HIE’s financing isn’t always on a sustainable footing. It seems that some programmes have initial non-recurring start-up funding but not longer-term finance.

    Issues from the study include: 

    Most evidence for health ICT impact’s from a relatively small number of centres, usually referred to as health ITC leaders that are typically large academic medical centres with internally developed health ICT systems, implemented incrementally, and refined over long periods, so unique It’s difficult to separate the effects of the health ICT from the confounding influences of the health system itself and clouds the scope to generalise benefits to the very different context of health system and hospital implementations of commercially developed systems over shorter periods with less internal development and implementation infrastructure. The overall model of health ICT purchase and installation of organisations no seen as health ICT leaders are usually different from the incremental internal development, implementation, and refinement by health ICT leader systems It seems that some health ICT, especially Clinical Decision Support (CDS), where systems evaluated by their developers tend to realise more positive outcomes from their evaluation than external evaluators find, so needs reflecting in HIE evaluations Most importantly, transferability of evaluation findings is limied, so predicting whether specific HIE projects in specific health care contexts will have favourable impacts on specific desired outcomes isn’t possible yet.

    Africa’s health systems can use this study to leaven their HIE plans with extra caution about the impact they might have and setting their long-term financial foundations. It also helps to set their focus on the benefits they can attribute to HIE and the wider eHealth initiatives needed to realise them.

  • When will HIE take off?

    A double feature of some eHealth is its combination of widespread implementation with low utilisation. It creates a double-edged sword of high costs with low benefits. A report on Health Information Exchange (HIE) from the USA’s Agency for Healthcare Research and Quality (AHRQ) found a similar phenomenon. It includes the HIE study lad by Oregon Health and Science University.

    It found increased HIE adoption by hospitals of 76% on 2014, an 85% increase since 2008 and 23% up on 2013. Alongside this, HIE was used by 38% of office-based physicians in 2012, and a miserly lees than 1% by long-term care providers.

    Within organisations with HIE, the number of users, or the number of visits, using HIE was very low. HIE usability was linked to higher rates of use, but not associated with effectiveness outcomes. Barriers to using HIE were: 

    Lack of critical mass electronically exchanging data Inefficient workflow Poorly designed interface and update features.

    It’s not known if limited HIE usability caused by its function or architecture. Constraints were drawn from external environments and organisations’ internal characteristics that affect implementation and sustainability. The most frequent were the characteristics of HIEs’ organisation, including leadership or specific characteristics of HIE. Disincentives such as competition, or lack of a business case for HIE were the most frequently identified barriers.

    Enabling environments includes some very challenging requirements that need integrating:

    General structural characteristics, including leadership and prior experience with, or readiness for, ICT projects, an existing membership in a network and trust and solidarity among participating practices Specific HIE structures, including governance, encouraging user engagement and stakeholder buy-in Orientation shift in HIE organisations, such as mission or ideology, switching from competition to collaboration, changing from data ownership to continuity of care to realise the value of external information, shifting from HIE activities as a pilot to integrating them in workflow, and not staying in the pilot phase too long Design characteristics need an understanding of work flow, perhaps adhering to smaller scale or more limited scope, and architecture and adaptability of information Key functions must ensure HIE becomes part of healthcare routines to minimise the burden and time required of staff Implementation support, including technical assistance, training infrastructure, ability for extensive testing for data quality and a comprehensive strategy for HIE activities Expected outcomes include public HIE awareness, links to communities’ needs, and establishing tangible intermediate goals to keep stakeholder engaged and foster ongoing support External policies, such as legislation and regulations.

    These comprise an enormous and demanding part of HIE projects. African health systems need all of them in place before they start on HIE.

  • Community HIEs' positive ROI's just a belief

    Evidence is important in healthcare. Bertrand Russell, the British philosopher and polymath said “The fact that an opinion has been widely held is no evidence whatever that it is not utterly absurd.” A study by a team in New Orleans and published in Perspectives in Health Information Management has found a similar phenomenon for community HIEs.

    It found that:

    67% agreed that community HIEs showed a positive Return on Investment (ROI) 33% had no opinion about ROI or disagreed Fewer than 25% said they used a range of metrics to calculate ROI Over half said HIEs improve healthcare quality 76% said they didn’t provide reports on quality measures 73% said data isn’t used to measure quality performance.

    Several participants weren’t sure about community HIE’s ROI and were waiting for more evidence. It seems they may be right. The study shows that while most respondents believe that the HIEs show a positive ROI, only a minority of them had used, or will use specific metrics to calculate it. Similarly, they overwhelmingly believe HIEs improve healthcare quality, but only a few use data to evaluate performance or produce reports on quality measures.

    The studies conclusions are that the growth in operational community HIEs hasn’t been accompanied by progress on producing knowledge about their ROIs or demonstrating quality improvements. It reveals the challenges of policy makers, healthcare executives and eHealth teams to measure and show HIEs’ value. Until it’s done, it “Raises serious questions for the sustained support of HIEs, both financially and as a policy lever.”

    This isn’t just a requirement for the USA’s healthcare and eHealth. All health systems have an obligation to show eHealth’s benefits and costs, so value. It’s needed before eHealth initiatives are embarked on and as rigorous M&E endeavour. A simple reason is that not all eHealth shows a positive value. 

    Immanuel Kant, the 18th century philosopher said he “Had to remove knowledge in order to make room for belief.” It’s not a good idea for eHealth. Africa’s stretched health systems can’t afford to go down the route of ROI belief.

  • Hospitals need better OI

    Healthcare’s complex, with lots of dependencies: nothing new about that. A study in Bio Med Central by a team from several USA institutions has put some numbers on part of it. Its aim is to construct a user needs assessment to inform Health Information Exchange (HIE) design and implementation to access Outside Information (OI). Its methodology can help Africa’s health systems in their eHealth endeavours.

    OI’s mainly needed to:

    Access laboratory or imaging abnormalities Understand medical history of patients either critically ill or transferred between hospitals Assess previous echocardiograms and bacterial cultures. 

    These needs for information aren’t very efficient. The study found that:

    Almost 14% of hospital admissions generate at least one request for Outside Information (OI) The average process comprised 13 steps, six decisions points, and four different participants 18 hours is the estimated average time to receive OI OI isn’t useful in range of 33 to 66 % of the time because it’s either irrelevant or too late Technical barriers to OI use included poor accessibility and ineffective information.

    The reasons for the poor performance are:

    Receiving extraneous notes Need for re-requests.

    HIE’s seen as part of the solution by 85% of doctors. They think it’ll improve healthcare. It’s the healthcare equivalent to Boeing’s durable philosophy of “Getting the right part to the right place at the right time.” It’s an objective that can inform and drive Africa’s eHealth initiative.

  • EHRs and HIE can help forecast demand

    When the USA’s State of Maine set up HealthInfoNet, its Health Information Exchange (HIE), it integrated predictive analytics into it with an online population risk surveillance dashboard. It allows researchers to conduct real-time surveillance for field staff and population health managers. It seems that it’s now paying off. A report in the Journal of Medical Internet Research (JMIR) says researchers have used the HIE to create an online risk model using EMR data to predict the healthcare resources patients need for the next six months.

    Some patients are the equivalent of frequent flyers. They’re a relatively small proportion of patients, but use a relatively large amount of healthcare resources. They have a specific focus in the risk model that focuses resources on them, and treating them separately.

    The model’s been tested for reliability at individual patient level and population level. It aggregated data from more than a million patients, and extended back over the previous year.

    Maine’s HIE initiative confirms a strategic goal for EMRs and EHRs in Africa. Initially, many benefits were seen to derive from sharing data between healthcare professionals. This’s still an important benefit, but now, using the data to forecast short-term demands and plan the availability and utilisation of healthcare resources steps up the benefits. Africa’s health systems can now include this, and the resources it needs in their eHealth plans.

  • HIE has five criteria to adopt

    With data sharing being core to eHealth, especially EHRs, adopting good practices are important. Health Information Exchange (HIE) is part of the solutions, and HIE Watch offers five themes to look out for.

    Advanced health models are making progress by making existing data actionable in new ways, but stakeholders need seamless access to analytics capabilities to make this data useful Community organisations are integral partners to advanced health models and are motivated to share data, but sharing across clinical settings and social services isn’t standardised, with weak incentives Some advanced health models are responding to interoperability challenges by granting community organisations access to a single platform instead of achieving interoperability (IOp) across different systems Mapping patient identities across data sets is challenging without consistent patient identifiers Health organisations need to think beyond EHRs when they’re developing data infrastructure.

    These are important themes for African eHealth projects to incorporate. Projects also need to ensure that their vendors help with these directly.