Attending the eHealth Initiative’s one-day forum on health information exchanges (HIEs) last week in Washington, D.C., seemed to validate all the perceptions I’d been gathering over the past year about the challenges and opportunities inherent in the HIE concept at this point in time. On the one hand, some real progress is being made, in places as far-flung as Vermont, Louisiana, and Arizona. On the other hand, the path has been, and continues to be, remarkably difficult, for a wide variety of reasons associated with funding, governance, affiliation, process, and other issues. And the technology is the least of it, though there absolutely do remain some tech issues as well.

Fundamentally, because every HIE is emerging out of a different individual situation, embedded in particularized geography, demography, industry relationships, and so on, every HIE is turning out rather differently, even given some very fundamental commonalities at certain deep levels. As a result, the situation is maddeningly complex, and doesn’t augur well for the rapid development of HIEs that federal authorities, policy leaders, and industry thought-leaders have been hoping for.

All this reminds me very much of reading about the early development of the automobile a little over a century ago. As hard to believe as it might seem, there was a very early phase in which it wasn’t even clear where the various basic parts of a car should go—the gas pedal, the brake, the clutch, the steering wheel, the driver’s seat, and so on. Not surprisingly, there were terrible road accidents as the very first, intrepid, drivers cranked up their engines and vroomed down the road (and not always on a universally agreed-upon side of the road, either!). It took a while, in fact, for a number of manufacturing, rules of the road, and other conventions to evolve forward.

The challenge with HIEs is that they are so very much needed, and that their development is proceeding forward in a time of intensified requirements and pressures. How long can we sustain this completely individualized model of HIE development? On the other hand, the alternative could well be the rigid development of exchanges that don’t serve the individual needs of their stakeholders or communities, and that would be even more frustrating. Just think back to the CHINs of the 1990s, or even the RHIOs of a few years ago—which were the same as the HIEs of now, except that the early and widespread failures of RHIOs led to their being renamed as HIEs…!

This is “so healthcare,” I have to say. But at this crucial juncture in HIE evolution, there seems to be little alternative right now. Hopefully, within the next two years or so, enough successful models will have evolved forward to the point where those who follow in their footsteps will be able to quickly choose from a relatively small-ish number of models to emulate. We certainly can’t afford ten years of tinkering before everyone agrees where the carburetor should be.