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The Book Hasn’t Been Written on HIEs Yet

March 4, 2015
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Health information exchanges (HIE), pegged with the unenviable task of getting disparate health systems and EHR vendors to actually work together in an era of increasing consolidated competitive pressure, died on the vine and everyone lived happily ever. 
In fact, they all went back to playing in the sandbox alone. 
Sorry, I was just writing the final chapter in the story of HIEs. Confused? Let me backtrack.  
This week, a study in Health Affairs, declared that the benefit of HIEs has yet to be proved in literature. Researchers from the University of Arizona, Weill Cornell Medical College, and the Indiana University School of Public Health did a scientific analysis review of 27 existing studies on HIEs’ effect on the cost and quality of care. What they found was that they couldn’t find anything conclusive.
“The current state of literature does not provide sufficient rigorous evidence for the benefits of HIE,” is the first sentence of the study’s conclusion. Of course, it does not provide rigorous evidence for the negative effects of HIE either. It kind of proved we know nothing. We knew that (I’m well versed in knowing nothing). The authors share three reasons that are likely for this for this lack of discovery: 
1) HIE use is still in its infancy
2) Studying the benefits of an HIE in a “real-world environment” is a challenge where a controlled trial is not feasible
3) Maybe, HIE’s benefits to reducing cost and improving care is overstated
It’s that third one that got the most attention. News outlets may have taken that tidbit and reported that HIE was not related to cost and care improvements. Of course, the study isn’t definitively saying that. 
What the authors say is that of the 27 studies on the effectiveness of HIEs in cost and care improvement, only six have “internal validity.” Basically only six used randomized controlled trials and quasi-experiments vs. the 21 that used a cohort study. Of those six, two found benefits to HIE, one said there was a negative effect, and three were inconclusive. 
The authors concluded that the benefits were inconclusive, based on the research that’s out there. They gave those three possible explanations as to why. Explanation three is given with a HUGE caveat. “Clearly, more research is needed before conclusions are drawn.” Yes, clearly. 
Maybe, the benefits to HIEs ARE overstated. There is no way we would know that at this point. As I’ve seen with HIEs, so few are in the latter stages of development that you can’t judge them right now. They may never get past that stage but the book hasn’t been finished yet. Most are striding along, working through the kinks you’d expect in a pioneering stage of technological development. Remember before the Health Information Technology for Economic and Clinical Health (HITECH) Act, a large chunk of this country didn’t even HAVE EHRs. 
In a industry where the walls are very real, where competitive pressure and consolidating healthcare organizations is an everyday reality, and information technology systems are in the infancy of deployment, we’re going to need more than a few years to judge HIEs. (I could have saved these researchers a few dollars and some time, FYI). 
Yes, there are tons of questions that remain. As my colleague, Mark Hagland wrote in his tech trends piece, the future of many HIEs is in doubt due to sustainability concerns. The technology is still a work in progress.  
Keep in mind though, most fairy tales (and forms of creative writing) have an “dark night of the soul” point (copyright, Blake Snyder author of “Save the Cat”). It’s the point where it seems like, yes, all hope is lost. Right then, the hero swoops in and saves the day. 
Obviously, real life isn’t a fairy tale and we’re very likely not to see any heroics in this story. As I said though, the story’s ending is far from over.  Let’s see what happens.