Blog from October, 2020

Christopher Jason

Following Nebraska’s social determinants of health data implementation, six additional states jumped on board.

Nebraska Health Information Initiative (NEHII), Nebraska’s statewide health information exchange (HIE), announced it’s expanding its behavioral health data platform, which includes social determinants of health (SDOH) data, to six additional states, including Iowa, Kansas, Minnesota, Missouri, North Dakota, and South Dakota.

The HIE will connect those rural states to the Unite Us platform. This social services network aims to connect health and social care providers to enhance care coordination and delivery across the six states.

“NEHII is thrilled to be expanding our partnership with Unite Us into six new states, to enable better support and health outcomes for all Americans,” said Jaime Bland, president and CEO of NEHII.

According to a common statistic, SDOH impacts roughly 80 percent of an individual’s health goes beyond clinical care and is impacted by SDOH.

Identifying and integrating SDOH data into the EHR can help find answers to a state or region’s most critical issues. However, most health systems face interoperability issues when implementing SDOH data into their respective EHR systems.

Through this partnership, citizens from all seven states can access nutrition services, employment and benefits, and housing. The platform is accessible to both healthcare and social services providers, and they can view healthcare data and outcomes data on the platform.

“We know patients don't seek care in a single institution, let alone a single state, especially along our borders,” continued Bland. “Statewide infrastructures for health and social care are more crucial than ever as COVID-19 continues to devastate the nation. We're eager to help additional states combine their clinical and social care data in one secure location to provide patients and providers a more comprehensive view of their longitudinal health record.”

Using one streamlined workflow, NEHII intends to address SDOH to avoid duplicative care, boost workflows, track results, and develop long-term, sustainable care models. Looking forward, NEHII said it hopes it can add additional HIEs, health systems, and Medicaid departments to the platform.

“Our ultimate goal is to help all Americans lead healthier lives, and this extended partnership with NEHII enables providers to better address whole-person needs, including nonmedical issues and social determinants of health,” said Taylor Justice, president of Unite Us.

This six-state expansion comes after HIE and network launched Unite Nebraska in June. The pair expect all networks to go live by August 2022.

A recent JAMA Network Open study offered a key example of how providers can use SDOH data integrated into the EHR for purposes beyond social services referral.

Researchers developed an SDOH screening tool, measuring common SDOH factors and deployed it with nearly 5,000 high-risk US Department of Veterans Affairs (VA) patients. The SDOH screener integrated into the EHR and researchers used it for risk analysis to predict hospitalization.

Overall, SDOH integration helped estimate hospitalization at both 90 and 180 days. Researchers directly correlated the results to the integration of resilience, marriage status, smoking status, health literacy, medication insecurity, and health-related locus control.

Following the study, researchers recommended integrating specific SDOH data into the EHR, including marital status, health-related locus control, smoking status, health literacy, resilience, and medication insecurity.

Christopher Jason

Health information exchanges across the country are boosting interoperability by connecting at the state, regional, and national levels.

Adequate and seamless health information exchange is an evergreen problem in healthcare, the adverse consequences of which are well-documented.

Poor data access can lead to patient safety issues, delays in care access, and tack on additional roadblocks to already cumbersome provider workflows.

But according to The Office of the National Coordinator for Health Information Technology (ONC) —and nearly everyone else in healthcare—electronic health information exchange (HIE) allows 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.

HIEs are looking at different ways to boost interoperability between more health organizations. To achieve these goals, health IT developers are broadening the digital footprint at state, regional, and national levels.


It took Connecticut numerous tries to establish its HIE, Robert H. Aseltine, PhD, chair of the advisory board for CTHealthLink, said it was a no-brainer for CTHealthLink to sign on with the statewide HIE, which will take on the name CONNIE.

Statewide HIEs reduce costs and improve care by eliminating the chances of duplicative testing. These statewide networks also link several providers without establishing a connection with each facility and identify health trends.

“With the state putting so many resources and so much effort and planning into this, it would be very difficult to decline,” he explained in an interview with EHRIntelligence.

“Once the state decided this was the direction they were going in, we were very pleased they chose a mechanism that allows for partnerships. This will allow us to be extremely successful in serving community-based providers and the types of physicians who may not have access to this type of technology based on their practice arrangements.”

The HIE leans on a network-of-networks concept. It aims to bridge existing health system networks together with independent hospitals and providers to enhance interoperability within the state.

With its first partner in the fold, the HIE can add more partners and develop long-term financial plans for sustainability.

“We really are the only functioning HIE in the state of Connecticut,” Aseltine said of CTHealthLink. “There have been other efforts to bridge certain facilities and outpatient practices, but not a full-fledged HIE.”

Aseltine also noted the HIE would be working on expanding these partnerships with other national exchanges in a way that provides a powerful demonstration of the scale they can achieve together.

“This echoes how important health data exchange is for physicians across the state of Connecticut,” Layne Gakos, JD, General Counsel of Connecticut State Medical Society, said to EHRIntelligence.

“We're excited to be where we are right now and to be the first one that's up and running. It's taken a lot of work. But it's been rewarding, and we believe it's going to be rewarding moving forward as the state moves forward in developing its HIE.”


A common issue with interoperability is that there are too many boundaries, making it localized. Some experts contend that HIEs should ease those boundaries to boost interoperability across the state —or even across state lines— for a more regional approach.

A regional HIE is currently growing in the western part of the country. Colorado Regional Health Information Organization (CORHIO) knew it needed to grow to reach a regional population and develop significant insights on larger populations and geographies.

CORHIO tapped a neighboring HIE, Arizona’s Health Current, to achieve this goal.

The two HIEs connect roughly 1,320 healthcare organizations, and the collaboration would significantly boost interoperability between those organizations in Colorado and Arizona. 

The two HIEs then needed to use common technologies and standards to create common services and products.

“The goal of all of this is to build out the infrastructure that we've been building for the last 10 years, and then take them to the next level,” said Morgan Honea, CEO of CORHIO.

The two HIEs will ultimately want a technical integration on a single data management platform to achieve these goals, where they migrate their respective technologies into a standard solution. But for right now, CORHIO and Health Current need to quickly integrate key data points to utilize as use cases.

“There are parallel paths that we can go down,” Honea said. “Some are more immediate opportunities, and some are going to be long term planning and integration strategies that we're going to have to go through. But without a doubt, one of the primary objectives of this is to create technology commonalities.”

While the two data exchanges are still in talks, they prioritize developing a model through entity structure and representative governance to encourage other HIEs to join the movement.

“That's what we're going to be paying close attention to over the next six months with our legal counsel and with the support of some of our peers,” Honea added.

“We are trying to develop a model that would be encouraging of other HIE's to join and be comfortable in a model that is fair and equitable in terms of governance, operations, and autonomy. But it focuses on leveraging economies of scale and technology commonalities. That is absolutely a top priority of this effort.”

CORHIO is aiming towards the ultimate goal of a nationwide model to further increase interoperability.


Leveraging existing health IT infrastructure is an essential component of the federal plan to achieve nationwide interoperability and successfully develop a learning health system.

The eHealth Exchange is a leading example of this plan.

More than 50 percent of the nation’s HIEs connect to the eHealth Exchange network. Additionally, 75 percent of all US hospitals, 61 regional or state HIEs, 70,000 medical groups, and over 8,000 pharmacies link to the nationwide exchange. In total, eHealth Exchange accounts for over 120 million patient records.

The eHealth Exchange was formed over a decade ago by the ONC and adopted a federated exchange approach. Policymakers opted to take an open-market and decentralized approach, rather than a required gateway, which would support further innovation. 

The eHealth Exchange utilizes the InterSystems platform integrated with eHealth Exchange’s FHIR healthcare directory based on the hub model.

The hub will make it significantly easier for organizations to connect, using a “connect once” model to reach any other member in the network. This method will facilitate streamlined access to patient records at lowered costs. 

The new approach will also help organizations prepare for regulatory changes, such as the interoperability rule and the Trust Exchange Framework and Common Agreement (TEFCA). 

In late 2019, eHealth Exchange implemented Carequality into the health information network to support additional exchange methods and to provide a standard gateway for all participants.

Carequality helps members reduce information exchange expenses, accelerate the implementation of innovative capabilities, and further expand their national footprint.

With additional large HIEs now connected to the network, the eHealth Exchange can adopt a more centralized health information network approach by providing a common gateway for all participants.

As participants continue to transition to the gateway approach, early adopters of the new architecture expand their focus to complete implementation of the Carequality Interoperability Framework

The Carequality framework is already in use by more than 600,000 physicians and is home to over 36 million patient records.

While HIE and interoperability problems run rampant throughout the healthcare industry, local HIEs are aiming to alleviate that burden by making strong connections at state, regional, and national levels.

Christopher Jason

Health systems are saving money after implementing CDS alerts into their respective EHR systems.

EHR-based clinical decision support (CDS) interventions have an overall positive economic impact on health systems, according to a study published in the US National Library of Medicine.

While researchers noted a lack of extensive cost components in their analysis, researchers acknowledged CDS interventions had a positive economic impact on health systems, such as reducing healthcare waste.

CDS tools enable prescribers to access real-time patient data, ideally resulting in enhanced patient safety and medication accuracy. CDS alerts can also prevent errors and additional adverse drug events from happening. Implementing CDS alerts into EHRs aims to reduce costs based on these typical health system challenges.

In a literature review of 27 studies, researchers aimed to evaluate the economic impact of CDS interventions based on EHRs. Researchers also identified and categorized CDS best practices.

Of the 27 studies, 22 studies noted a positive economic impact following CDS implementation. The implementation of CDS tools lowered costs on laboratory testing, antibiotic prescriptions, transfusion practice, and decreased duplicate order entries.

However, researchers also found previously undiscovered CDS malfunctions, order facilitators, and maintenance costs that could lead to added costs for a health system.

“While high upfront and maintenance costs of CDS systems are a worldwide implementation barrier, most studies do not consider implementation cost,” explained the study authors. “Finally, four included economic evaluation studies report mixed monetary outcome results and thus highlight the importance of further high-quality economic evaluations for these CDS systems.”

While researchers found several studies to show the economic impact, the study authors said evaluating this impact and its future value remains a significant challenge for researchers. The 22 studies reporting cost savings did not highlight how CDS solutions maintained or developed costs.

“Therefore, we could not draw a sound correlation between vendor-purchased or home-grown systems’ costs to their economic benefit,” explained the study authors. “Nonetheless, this study reveals several use cases with coherent CDS tools that have proven to be cost-saving and could be eligible for other healthcare providers, clinic managers, and researchers for implementation or further exploration.”

Researchers questioned the increasing number of CDS interventions based on point-of-care alerts, how much algorithm-based systems and numerous interventions would impact health system costs.

Health systems will have to consider the number of alerts, time expenses, and process-cost analysis to better understand the entire CDS economic impact, said researchers. Even implementing comparative metrics to assess the cost per useful alert could be a better way to look at these numbers.

“In a simple model, the authors introduce this measure to analyze how different parameters affect the cost of implementing EHR based CDS alerts for genomic precision medicine,” wrote researchers. “However, for future economic evaluations of EHR based CDS interventions, a more specific approach for individual application areas or focus on medical risk factors is needed to draw meaningful conclusions from cost and outcome comparisons.”

On the other hand, researchers said computerized physician order entry (CPOE) systems with automated lists and order sets could increase costs, thus, decreasing the value of CDS alerts.

“For example, the rate of unnecessary laboratory tests can increase when healthcare professionals tend to accept the whole order set rather than de-selecting single order items,” the study authors said. “This can be explained by alert fatigue, which must not directly be related to the order set, in combination with the ‘button clicking syndrome’, which explains the inducement of moving along inattentively.”

Extensive research is needed to come to a concrete conclusion, but researchers found CDS interventions have a positive economic impact.

“Predominantly point-of-care alerts concerning unnecessary laboratory testing, efficient transfusion practice, or reduction of antibiotic prescription emerged as application areas with already promising potential for high-cost savings,” concluded study authors.

“Nonetheless, most studies lack consideration of coherent cost components as well as comparative metrics. Therefore, the economic dimension of EHR based CDS interventions needs to be further explored.”