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What We Know About the “States” of HIE

January 9, 2015
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During the Christmas/New Year’s two-week window, the Office of the National Coordinator for Health IT (ONC) released a report on the State Health Information Exchange (HIE) Program. The report was written by NORC, at the University of Chicago.

This may sound like a broken record, but the release of this report comes at a time when HIE sits at a crossroads. I know I’ve said it before, but I’ll say it now and I’ll say it again, until it’s no longer at a crossroads. HIE is at a crossroads, specifically statewide exchange efforts.

Some, thanks to the efforts of people like Dev Culver in Maine, have succeeded and are doing quite well. Others are not. The report, in 42 pages, did a fine job of detailing this reality. It was a nice overview of the successes and challenges of HIE at large, and yes, it comes at a critical time. With the end of State HIE Program, it’s unclear where the larger data exchange efforts will go. Will they successful or will they fall apart without funding?

For the report, NORC looked at six states. They did a bang-up job of picking six states that, while obviously having unique problems, represent the nation at large. The six states were Iowa, New Hampshire, Wyoming, Mississippi,  Utah, and Vermont. If they picked six winners or six losers, it wouldn’t have told the complete tale. These are six HIEs that are at varying stages of development.

It was broken up into various sections, including how each grantee enabled exchange from a technical perspective, what policy-levers they used, how they engaged stakeholders, and what were their plans for sustainability. So what did the report tell us about HIE at the end of the State HIE Program? Let’s dive in and break down each section.

Technical Perspective: Everyone has taken on Direct exchange, meaning participants can “subscribe to regional- and state-level entities that facilitate exchange across unaffiliated organizations for directed exchange.” Interest in Direct has grown over time, the report’s authors indicate. Despite this, workflow challenges with Direct are still present. The lack of electronic health record (EHR) integration, for one, is frustrating. On the flip side, Query-based exchange, available in four of the six states, is based on one of three technical models: federated, centralized, or hybrid. The federated model seems to be favored by those who have done it, but they caution say it’s costly and time-intensive to connect through. Centralized participants say it allows for easy data access, is good for analytics, and offers a consolidated view. However, it requires more up-front costs. Later on, authors of the report talked about the challenges related to the HIE developers. Not shockingly, those who worked closely with their developer did better than those who did not. Also, HIEs are leaning towards best of breed, rather than a single HIE vendor, due to the latter’s limitations. This was the case in Utah.

Policy Levers: The key finding here was the importance of accountable care organizations (ACOs). In states where there was a rise in ACOs, HIEs were found to be fundamental. This was the case in both Vermont and Iowa, which had progressed more than some of the other states in the report. Another finding was opt-in and opt-out. Basically, opt-in is a problem. It was an impediment in Utah, until policy ensured that data for Medicaid, Medicare, CHIP, and Public Health Employees Program beneficiaries would be in the HIE

Stakeholder Engagement: This is where the men were separated from the boys, as they say. States that were able to get big-time health systems and organizations on board (Vermont, Utah) early on made a lot more progress than those that did not (Wyoming, Mississippi). The latter did have representatives from two big hospitals, but failed to establish a relationship with Medicaid. All six states said the regional extension centers (RECs) were an important part in engaging the community. One element to overcome engagement challenges was the establishing incremental goals to give the stakeholders quick, early wins. In the states where HIE succeeded, this was a much better option than the “build and they will come” approach. Another interesting find was how elements out of their control—i.e. market consolidation—affected progress. Markets with more consolidation (Vermont) had a clearer path towards engagement of large health systems.

Sustainability: If the men have been separated from the boys in stakeholder engagement, what happens in sustainability? The strong men get separated from weak? An HIE that has already shuttered (Wyoming) wasn’t even included in this section. What did the states that had success find? Value-added services! It’s the term, like crossroads, that cannot be overstated enough. In Vermont, they were looking at analytics. In Utah, it was alerts and Stage 2 meaningful use criteria. Iowa has a whole bunch of value-add: ePrescribing, CCD exchange, lab and radiology results, etc. While the fee structure is different among all these states, the idea behind sustainability is not.