Healthcare policy researchers have published two very important articles in the current, July issue of Health Affairs, that look at aspects of the health information exchange (HIE) phenomenon. Both are thoroughly researched, with a great deal of detail and of nuance, and I would strongly encourage Healthcare Informatics readers to read both articles very carefully and thoughtfully. What’s more, both sets of (overlapping) researchers come to conclusions which, though stated with great diplomacy, are quite significant in their implications. So let’s plunge in and consider both articles.
The two articles are entitled “The Number of Health Information Exchange Efforts Is Declining, Leaving The Viability Of Broad Clinical Data Exchange Uncertain,” authored by Julia Adler-Milstein, Sunny C. Lin, and Ashish K. Jha; and “Engagement In Hospital Health Information Exchange Is Associated With Vendor Marketplace Dominance,” by Jordan Everson and Julia Adler-Milstein. Both articles were extremely carefully researched (with very detailed explanations of study data and methods in both); I won’t go into the very complex details here.
But let’s begin by summarizing them as saying, essentially, that, per the first article, HIE appears to be a fairly fragile phenomenon in the wake of the loss of most federal and state funding in the past two years—something that has been widely known—with a strong need for operating HIEs to prove strong market value (though that term is not used) in order to survive; and, per the second article, even more diplomatically stated, intense market dominance by a few large electronic health record (EHR) vendors is having a huge impact on how HIE is pursued in markets in which a single vendor dominates. Fascinatingly, the authors of the second article do make it clear that the impact of market dominance on the part of the Verona, Wis.-based Epic Systems Corporation is quite different from that of market dominance on the part of any of the other largest EHR vendors—the Kansas City-based Cerner Corporation, the Chicago-based Allscripts, or the Westwood, Mass.-based Meditech. With regard to that second article, as much is left unsaid as is said—but more on that shortly.
The first article, by Adler-Milstein, Lin, and Jha, is in some ways the more straightforward, though the arithmetic involved is a bit mind-numbing. As the authors state in their abstract, “The diffusion of health information exchange (HIE), in which clinical data are electronically linked to patients in many different care settings, is a top propriety for policy makers. To drive HIE, community and state efforts were federally funded to broadly engage providers in exchanging data in ways that improved patient care. To assess the current landscape,” they write, “we conducted a national survey of community and state HIE efforts that, as a group, engaged more than one-third of all US providers in 2014. However, the number of operational HIE efforts is down from 119 in 2012, representing the first decline observed since the tracking of these efforts began in 2006. Only half of operational efforts reported being financially viable,” they note, “and all efforts reported a variety of barriers to continuation. These findings raise important questions about whether the current vision for HIE efforts will allow for the broad exchange of clinical data, or whether alternative approaches would be more successful.”
Adler-Milstein, Lin, and Jha go into very extensive detail writing about the current landscape of HIE in the U.S.; suffice it to say that the bottom line is one that has become clear to everyone in the HIE world, though it is highly commendable that these researchers have documented the phenomenon in such detail. Essentially, they find that HIEs are stumbling in attempting to sustain themselves now that federal and state funding have for the most part evaporated, with not enough hospitals, physicians, or health insurers willing to actually pay for simple sharing of summary of care documents. “Developing a sustainable business model was the most prevalent barrier to HIE progress in both 2012 and 2014,” the authors note. “This was closely followed by integration of HIE into provider workflow, a barrier that we asked about for the first time in 2014. Lack of funding, a second financial barrier, was reported as substantial by almost the same percentage of respondents in 2012 and 2014. Two other barriers asked about for the first time in 2014—limitations of current interface standards and lack of resources to implement interface standards—were also identified as substantial barriers by roughly one-quarter of the respondents,” with 20 percent of respondents also citing “competition from health information technology vendors offering HIE solutions as a substantial barrier in 2014—and increase from 2012.”