I got the distinct privilege to moderate the "Health Information Exchange: Strategies and Sustainability" panel at the HCI Executive Summit on May 8, held at the World Center Marriott in Orlando, Fl. It was exceedingly interesting to hear what challenges and breakthrough my panelists were having, as well as hearing them parse some strategies in HIE advancement, and the talk about some of the lessons being learned around sustainability, data sharing, and governance models.

What I found most interesting was the diverging approaches to sustainability. Devore Culver, executive director and CEO, HealthInfoNet, Maine’s statewide exchange, had strong feelings about the act of health information exchange not being sustainable by itself. “There’s no money in it, and there’s no one paying you to do it,” he said. “It’s other things that help you be sustainable. At the end of the day it’s all about the data.”

Culver said that 34 of Maine’s 39 hospitals will be connected to HealthInfoNet by the end of this year and a total of 1,000 providers will be connected by next year. He said that provider subscription fees will only be making up 50 percent of revenues because license fees have already been purchased by connected hospitals. HealthInfoNet subscribers range from critical access hospitals paying $25,000 a year to large facilities paying $200,000 a year. Culver said to cover the remaining amount of revenue this summer, HealthInfoNet would be standing up an image repository, which the exchange can take a margin off the top, to help coordination of care by eliminating cumbersome image CDs.

Nebraska has taken an interesting approach to sustainability by creating a subsidiary, HIO Shared Services (HIOSS), specifically to sell its services to the Nebraska Health Information Initiative (NEHII). Currently, 66 percent of the licensed beds in Nebraska, or 30 out of 89 hospitals, are connected. Many of those that aren’t yet connected are small four-bed or fewer hospitals. Christopher Henkenius, program director of HIOSS Inc. and NEHII, said that NEHII’s subscription model has worked so far with providers paying as little as $240 a year for full query access to the HIE.

Henkenius said that HIOSS has been in conversations to collaborate with Wyoming, the least populated state in the U.S. ,to share HIE services. “So instead of having two different infrastructures, or two different public health gateways, there’s only one public health gateway that two states use, effectively cutting the price in half for both states,” said Henkenius. Henkenius also said that HIOSS was working to provide Wisconsin with exchange services as well.

Another area that has been a useful application of NEHII is prescription drug monitoring, being one of the first states to use the exchange to combat drug seekers, said Henkenius. “So the emergency departments in Omaha and across the state are very excited about that function,” he said. “Because Nebraska didn’t have one, and we have a lot of drug seekers from other states coming to Nebraska for prescription drugs and NEHII’s medication history functionality is able to identify and treat those.”

However, there was one panelist, Mari Jo Rugh, vice president application services, Poudre Valley Health System, who was dubious of the sustainability of her region’s exchange, the Colorado Regional Health Information Organization (CORHIO), and was having a hard time justifying the value of exchange to her health system.

“Subscription-based [models] presents challenges from a sustainability perspective,” said Rugh. “I don’t know that all states are going to be able to overcome that, and we’re taking an approach of wait-and-see, if it truly gives us value then we’ll continue, but if we don’t see that value, then we’ll probably won’t subscribe anymore.”

Rugh did admit that care coordination would be a driving factor for exchange, as she’s has started discussions with a cardiology group in her system surrounding duplication of lipid panels that both cardiologists and PCPs order. “I think the medical home model and ACO model will become a sustaining driver for HIE,” she said. “I think that will be one of the reasons why HIEs survive.”