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Health Information Exchange: Are We At An Inflection Point?

August 30, 2013
by Mark Hagland
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As HIE evolves forward, healthcare leaders debate about continuing obstacles to granular-level data exchange

The concept of health information exchange (HIE) is far from new; indeed, as those who have been around the healthcare industry long enough can attest, we are already into our third iteration of the concept, with community health information networks  (CHINs) first emerging in the early 1990s, followed in the first decade of this century by regional health information organizations (RHIOs). With core problems around governance, local market competition, financial sustainability, and basic information technology plaguing CHINs, most died a relatively quick, though painful death; and most RHIOs faced severe governance and sustainability issues.

In contrast, the number of HIE organizations nationwide has grown dramatically in the United States in last few years, with the federal Agency for Healthcare Research and Quality (AHRQ) estimating that there are currently over 280 HIEs, and that more than 50 percent of the hospitals in the country are participating in HIE organizations. The same article on the AHRQ Web site that cites those figures cites achievements that have already been documented for HIEs. These include “reduction of duplication and operational costs”; “improvement of quality and health outcomes”; “improvement of public health surveillance”; and “strengthening of links between health-related research and actual practice.”

What’s more, virtually all responsible leaders across the U.S. healthcare industry support the concept of health information exchange; and HIE is enshrined in the Health Information Technology for Economic and Clinical Health (HITECH) Act, through the meaningful use process.

Even as HIEs continue to grow in number and in breadth of scope, healthcare leaders within and outside HIE organizations see stumbling block after stumbling block facing the sector in the next few years, and are asking what, if anything, could be done at the federal level to address the problems they see as hampering the long-term success, stability, and sustainability of health information exchange. Among the problem areas they see are:

• The lack of highly granular data-exchange standards—with some in the industry arguing for federal government intervention in that area;
• The broad lack of interoperability between HIE processes and electronic health records (EHRs);
• A combination of financing and governance issues that speak to long-term sustainability problems: many existing HIEs got their start through federal and/or state grants, many of which are now expiring or have expired; and unless consensus-driven strategies can be developed, many HIEs will falter once the grant money runs out;
• Underlying this, a failure to achieve alignment of goals among the stakeholder groups in HIE organizations; and
• A failure on the part of vendors, according to many industry observers, to provide the leading-edge technologies needed to break through EHR interoperability-related and other barriers.

All of these issues are becoming clearer at a time of intensifying need for HIE, in order to support accountable care organizations (ACOs), bundled-payment contracting, patient-centered medical home (PCMH) care models, clinical integration, value-based purchasing, and myriad other strategic goals in U.S. healthcare. In short, say many healthcare IT leaders, health information exchange is at an inflection point of its evolution in the current policy and operational environment.


f there’s anyone in the U.S. who can speak to where HIE is right now, where it should be, where it’s been, and where it’s going, it might be Devore (Dev) Culver, executive director of the Portland, Maine-based HealthInfoNet, the statewide HIE for Maine, which has all 38 hospitals in that state under contract. Incorporated in January 2006, HealthInfoNet has benefited from clear-sighted vision, broad stakeholder consensus, and clearly articulated need, in a state that, outside of a few cities, is largely rural, and where market competition is less of a factor than in many states.
Not only is HealthInfoNet a beehive of data and information exchange, with 3 million messages transmitted a week, and 84 percent of the state’s 1.3 million people represented (there are actually 1.2 million lives in the HIE, but some are also vacationers); Culver and his colleagues are currently building analytic tools to sit on top of their HIE’s data warehouse.

The key lesson so far in HealthInfoNet’s success? “The single most important early lesson was initially building that trust framework that allows information to be shared across competitors,” says Culver. “The second lesson is to treat this like a business. At the end of the day, if I can’t add tangible value, you’re probably not going to pay me. That’s the root challenge across the country when we look at health information exchanges. So here I am, a not-for-profit organization, but revenue has to exceed expenses, or we’ll go out of business. Over the last three or four years, the concept of an enterprise exchange has come onto the table, where a group of hospitals or providers reach out and build a private exchange.”