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Making Sense of the OIG Opinion on HIE

by Dan Orenstein, Senior VP and General Counsel of Legal

On Jan. 5th, we issued a press release about the positive advisory opinion we received from the HHS Office of the Inspector General (OIG) on our athenaCoordinator service pricing. Insiders have observed that it is different from other OIG advisory opinions on referral management arrangements because it enables transaction-based pricing for value-added health information exchange. 

This is an opinion that was sent to athenahealth and only applies directly to athenahealth. However, it was made public, so many in the industry (mostly lawyers!) will look at it for guidance on other health information exchange (HIE) arrangements on which they may be advising clients.

There is a lot of legal language in the opinion, which can make it a little difficult to understand exactly what athenahealth plans to do with its athenaCoordinator service. Some commentary I’ve seen in the blogosphere and elsewhere has mistakenly referred to our service as a “private HIE.”

It’s not.

For starters, athenaCoordinator is cloud-based and it’s a service that provides order transmission, insurance pre-certification and patient registration among physicians, hospitals and other care nodes. It’s intended to eliminate the errors and redundancies that can impede the flow of care in our health system. When you travel through the care chain, you should be a known entity at each stop and not someone who has to re-establish your identity and health information with each iteration.

As for how athenaCoordinator is not a private HIE, let me try to cut through the legalese (as well as a General Counsel can reasonably do) and explain why athenahealth’s plans are innovative and different. 

1. Everybody is welcome – One of the big problems with the effectiveness of HIE is that HIE systems, both public and private, are typically open to only limited regions or markets. With public HIE, this is a result of governance and funding—they tend to be focused on specified regions and the administrative and technical barriers to sharing useful information limits their reach. Private HIE is typically and intentionally targeted within specified health systems or regions based on business considerations. The ultimate intent of athenaCoordinator is to make the data exchange services available to anyone in any market in the United States. We believe that widespread participation results in a stronger network, leading to better information quality and therefore better care coordination.

2. It’s sustainable – Rather than relying on the largesse of public or private grant funders or donors, the transaction-based pricing enables a sustainable market for health information exchange.

3. Information is “on demand” – The idea is that users will pay for valuable information, what they want, when they want it and that they will pay fair value for it. The model de-emphasizes complex legal or administrative structures. Subscription is simple. athenaNet will serve up the information in a usable format. If it’s not eminently usable, customers won’t pay for it!

I will be candid. Effective nationwide HIE is a tough nut to crack. A lot of smart people have been working on HIE for years under more traditional models and most such models have failed.

Many are skeptical these arrangements can succeed. Yet most in the industry acknowledge the immensely powerful benefits of nationwide HIE.

So what makes us think that the athenaCoordinator model will work? It already does work to a large extent through the services offered by athenaCoordinator, known as Proxsys, LLC prior to our acquisition—including care coordination services to hospitals, ambulatory surgery centers (ASCs), and imaging centers. The changes planned by athenahealth for the athenaCoordinator service will expand these services and multiply the value of HIE by leveraging the demographic and clinical data of clients who subscribe to our EMR service, athenaClinicals.

Leveraging the other athenahealth services will enable more streamlined workflows and powerful reporting. This supports care coordination and more effective participation in payment programs that provide incentives for demonstrating adherence to care protocols. Of course non-athenahealth clients will be able to send to subscribing receivers as well. They will realize many of the benefits and their participation will strengthen the network power that enables better coordination.

We are heartened by the OIG’s policy approach that’s reflected in the advisory opinion. It recognizes the potential of free market approaches to accelerate the development of sustainable HIE in conjunction with government programs to support HIE and the use of EMR.

Will it work? Here at athenahealth, we know we’re creating an offering that tackles key barriers to effective, widespread HIE. We are trying to eliminate the silo-ing of information and create an economically sustainable model to exchange only valuable information when and as demanded. We also hope that our continuing engagement in the dynamic health regulatory environment stimulates more innovative models to solve these and other problems.   

Do you have any thoughts on HIE and care coordination? If so, send in a comment and let’s start a discussion…

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