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Nursing Leadership Informing Community Health Information Exchange Strategy
You are in the chief nursing officer role and have been asked by your healthcare system to represent the hospital on the board of a new not-for-profit entity established by your community to build and manage the HIE within your region. Your region has been awarded a federal grant of $250,000 to build the HIE to serve the community. At the first board meeting of diverse stakeholders, including payers, providers, hospitals, public health, and healthcare consumers, the group must advise the chief executive on what type of exchange the group believes is needed. The chief executive indicates that a basic exchange using the Direct Project protocols for the size of the community is likely to exceed the federal grant dollars, and as such, the group needs to align on a value proposition of what the community needs. This is hoped to result in the community being willing to pay for the additional costs.
The community has a population of more than 250,000, with a significant indigent population that tends to use the ED as an access to care for routine healthcare needs. Hospital staff also suspect that they have drug seekers going from one ED to the next seeking additional medications, yet do not have the information to confirm this suspicion or to track patients from one institution to another.
The community has two major healthcare systems that are heatedly competitive and unlikely to be willing to share data in a central data repository. Providers in the community compromise one large-practice consortium and multiple independent providers. The large group of providers is demanding that some sort of exchange be established to support their referral base. As a result, there is heated debate as to whether the community aligns with a business and infrastructure strategy.
1. Based on the needs of the community noted in the case study, what is your recommendation as to the best infrastructure and technical exchange model that the community should promote?
2. What are some of the barriers consistent with other communities’ failures that might be issues for your community and how do you overcome those issues?
Sample Answer
As the Chief Nursing Officer, my recommendation will prioritize a model that addresses the community's urgent safety and cost issues while respecting the existing competitive climate and budgetary constraints.
1. Recommended HIE Infrastructure and Technical Exchange Model
Given the community's critical needs—managing the indigent ED population and identifying drug seekers—and the significant barrier of fierce competition between the two major health systems, I recommend promoting a Query-Based Exchange model built on an Opt-In/Hybrid Infrastructure.
Recommended Model: Query-Based Exchange (HIE)**
This model is the best fit because it provides immediate access to critical, up-to-date patient information without requiring the competitive health systems to surrender their data into a single, centralized database.
This model offers a strong value proposition: "Immediate access to critical patient safety data at the point of care." This value is tangible and directly impacts clinical decision-making, justifying the community's need to cover costs beyond the initial grant.
2. Potential Barriers and Mitigation Strategies
While the Query-Based model mitigates the competitive barrier, other common HIE challenges could undermine success:
A. Non-Financial Barriers and Mitigation
Barrier
Description of Issue
Mitigation Strategy
Trust and Governance
Issue: The history of "heated competition" means providers may still be reluctant to trust the HIE's governance body with their patient index data, fearing misuse or security breaches.
Mitigation (Legal/Policy): Establish a neutral, transparent governance structure with a clear, legally binding data sharing agreement detailing strict "terms of use" for querying data (e.g., only for treatment, payment, or operations – TPO). Use a tiered voting structure that ensures no single competitive entity dominates the board.
Physician Workflow Integration
Issue: If the system is not easy to use (requires logging into a separate portal), the "large-practice consortium" and independent providers will ignore it, causing the HIE to fail due to low utilization.
Mitigation (Technical/Training): Ensure seamless EHR integration (using APIs or standards like FHIR) so the clinical summary can be accessed with minimal clicks directly within the existing electronic health record system. Mandate comprehensive training focused on how HIE access saves time, rather than costs time.