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Health Information Exchange: Moving Forward or Stuck in Neutral?

April 22, 2014
by Rajiv Leventhal
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In a still-young, but growing market, debate has arisen on whether or not HIE is headed in the right direction

Recent reports say that the global health information exchange (HIE) market is projected to reach $878 million in 2018, growing at a compound annual growth rate of 9.5 percent from 2013. This is due to factors such as incentives by the U.S. federal government, improvements in patient care and safety, and reduction in healthcare costs. However, issues such as high implementation costs, slow returns on investment, and interoperability problems are hampering the growth of this market.

As such, even as HIE technologies continue to grow in number and in breadth of scope, many healthcare leaders within and outside HIE organizations see stumbling block after stumbling block facing the sector over the next few years, and are asking what, if anything, could address the problems they see as hampering the long-term success, stability, and sustainability of health information exchange. Within these challenges lie vendor-market uncertainties. A report in March from the Orem, Utah-based KLAS research of 219 HIE providers found that overall provider satisfaction with HIE solutions dropped an average of 8 percent since last year, as provider demands outpaced vendor delivery. According to the report, grants are exhausted, public HIEs are struggling, and vendors are trying to deliver long-term value. At the same time, most vendors continue to experience flat or falling performance scores from customers, the research shows. Is this an inflection point for health information exchange?

Vendor executives, provider executives, and HIE leaders all have concerns. Sumit Nagpal, CEO of Alere Accountable Care Solutions (ACS) a Waltham, Mass.-based vendor with an HIE solution, says the industry has been stymied because of all the challenges that the vendor community has put up for the industry. “The vendors still have not really bought into opening up their silos and making data available for everything that they are needed for, because they haven’t figured out what they will be giving up by making that happen,” Nagpal says. “The provider organizations are wrestling with the same real considerations—what advantages are they giving up that they worked so hard to create?”

Sumit Nagpal

Nagpal goes on to say that for vendors, the sacrifice is clear: one vendor “winning” means some other vendor “lost,” so really, the way the vendor community is growing is by taking business away from other vendors, he says. “Essentially, they’re saying interoperability is a bad thing. Best-of-breed is dying a slow death for that reason. It’s much more of a benefit to the leading players if their own systems are involved in all the departments rather than making it easy for customers to pick and choose what they would like. They would be giving up a significant advantage—that’s the vendor problem.”

The provider problem, Nagpal continues, is that if providers give transparency into patient information, that puts the patients more in control of where they go and seek care, and puts other providers on a level playing field, as patients can alternate their sources of care. “Patients and providers can shop around, and this is the real business reason why HIE is not flourishing,” says Nagpal.

According to Micky Tripathi, Ph.D., CEO of the Massachusetts eHealth Collaborative (MAeHC), in some ways, demand has outpaced delivery, as providers certainly want to do things that vendor technology doesn’t allow right now. “Part of that is a vendor technology issue and some of it is an ecosystem issue,” he says. “In some cases, the vendor technology itself won’t do the kinds of things that a provider wants, such as a customized continuity of care document [CCD] for different use cases, where the technology might only be programmed to do a meaningful use compliance CCD, and that’s it. That’s not very nimble, it’s a vendor restriction,” says Tripathi. “The ecosystem restriction would be, ‘My vendor could do these things, but I have no one else to connect to.’ They’re on a different system or in a different HISP [health information service provider]—in a way, many of the issues we’re experiencing today feels like the early days of email.”


Chuck Podesta, senior vice president and CIO of Fletcher Allen Health Care, a Burlington, Vt.-based integrated health system, says things are getting more difficult, rather than less, in HIE as everyone is trying to find a sustainability model. “I think the solution for these HIEs is really their partnerships with accountable care organizations (ACOs). I’m on the Vermont Information Technology Leaders (VITL) board, so part of our sustainability strategy is to really connect with these ACOs, because we can charge a per-connection fee,” he says, “and in some of the smaller ACOs, the HIE can even be the analytics partner as well. But it’s very hard to show value to an individual physician’s office, and charge that individual physician for each use. That’s a really big struggle. So if you can’t connect with an ACO, it’s going to be difficult.”

Contrary to Podesta’s and Nagpal’s beliefs that HIE isn’t flourishing—there are still only a handful of success stories (in the tens, not the hundreds or thousands), simply because it’s an early-adopter market, Nagpal says—other health IT leaders, including Tripathi, feel that health information exchange is indeed thriving.

Micky Tripathi, Ph.D

“The biggest challenge for HIE the noun is that HIE the verb is flourishing,” Tripathi says. Before, there was the HIE concept of being an organization that would aggregate data and do all sorts of things with that data, with the idea to collect data once and use it for multiple purposes, he says. Now, Tripathi notes, HIE has become incredibly tactical and is very much in the hands of private actors who have a high demand for it. “Technology has enabled people to do HIE in many different ways, and because of that, supply is responding. It’s hard for me to run across a hospital or hospital system that doesn’t have some sort of HIE plan. Now, that doesn’t mean it’s a good plan or it’s even being executed, but all of them have a plan,” he says.

Mark Elson, Ph.D., principal at Intrepid Ascent, a Berkeley, Calif.-based consulting firm, agrees with Tripathi. “I don’t understand what people mean when they say HIE has become too difficult,” he says. “With the increasing number of national standards for exchange that are being adopted, it makes it much easier to connect disparate systems. Connecting data five or 10 years ago was not the same as it is today. There will always be customization, but that is decreasing as national standards proliferate; so, while it is hard, I don’t believe that it’s becoming harder. It’s just that now, more people are trying to do it.”

Nancy Ham, CEO of Medicity, a Salt Lake City-based HIE vendor, says that while technically HIE is challenging, there is plenty of proof that it works. “There are a lot of systems to connect, you have to appropriately resolve patient identity, appropriately manage patient consent at a granular level with a lot of different models—not just opt-in or opt-out, but opt-in or opt-out by data source and type of information—and support all these emerging use cases,” she says. As such, smaller, stand-alone companies are struggling because they don’t have the access to capital to keep up, and don’t have access to create automation and self-service tools, she says. “Right now, if you’re not growing, you’re falling way behind, but not everyone can sustain the pace that is required. Does it need to be easier? Yes. Connectivity needs to be better, faster, and cheaper, and as an industry we can do more about that,” Ham says.

Nancy Ham

Why is there a disconnect among industry leaders regarding how well HIE is doing? Tripathi says it’s because there is an impression that interoperability has been a failure up until now. There was once a sense that there would be a nationwide physician health information network, and there would be sub-networks and a common set of rules. Those expectations have been had for many years, he says. “Then you have these HIE organizations that were also a part of that vision with the idea of bringing the data together and normalizing it with a particular paradigm for what health information exchange is, but the reality now is that what is happening is what we have seen in other industries—it’s very tactical, solving very immediate problems, and it’s market based,” he says.

What that means is that it happens in patches, it’s not the same everywhere, and it’s also incremental, Tripathi continues. “You solve a problem, wait to see what happens, and then go from there for the next problem. That creates a frustration because of the expectation that you should be able to connect with everyone. When email or phone systems first developed, it took a long time to get to the maturity to get to where they are now, and the same holds true for HIE,” he says.

Those who believe that HIE is flourishing will point to the organizations and areas that have had success. In Texas, for example, progress has been made in implementing HIE infrastructure, says Tony Gilman, CEO of the Texas Health Services Authority (THSA), which was created by the Texas Legislature in 2007 as a public-private partnership to promote and coordinate HIE. The state has 10 HIEs that cover all of the major urban areas in the state, and have committed to connect 85 percent of all physicians and hospitals. Over the last calendar quarter of 2013, more than 32,000 clinical and administrative staff were enabled for query-based exchange, he says.

Tony Gilman

“Sustainability is definitely a question for us, in that our HIEs are primarily operating on subscription models, and that approach works in large metropolitan areas, but concerns remain about the financial capacity of smaller communities to sustain HIE infrastructure long term.” Gilman says. “We know through monitoring successful HIEs around the country, that success is linked to the number of users contributing data. Once an HIE achieves a critical mass of data users, that’s pretty significant, and then, HIE has shifted from being used as a verb to as a noun.”

To be in the population health and ACO game, there is a need to clinically connect to a community one way or another, and that foundation is the critical asset to power new business models, adds Ham. “If you don’t have anything yet, you’re late and need to get going. Population health analytics alone is insufficient. Analytics are above the water line, and while that’s beautiful and fantastic, what is below the water line is even more important. What is the quality of the data? Do you have 100 percent connectivity? Is it in real time? Do you have robust patient matching? Do you manage patient privacy?” On top of that, says Ham, an organization’s network should support multiple analytics tools rather than be closed in. “If you’re just an old school HIE, you probably don’t have the right partner to take you into the future.”


The next big peak to scale in HIE is ambulatory data, says Ham. For the past 10 years, the focus has been on getting information into electronic medical records (EMRs), and now everyone wants to get data out of the EMRs and do query-based connection across networks, she says. “These are no longer your father’s HIEs. We’re not talking pipes and plumbing anymore—that’s yesterday. What we are talking about is network-enabling population health, and helping our customers who have built up these strategic data assets over a period of years now use them and pivot for a whole bunch of new use cases, which is where the industry is focused. Taking the data on the network and using it to engage patients will become key—it’s one of the drivers of Stage 2 of meaningful use.”

Undoubtedly, some of the most important aspects in the rules for Stage 2 meaningful use pertain to patient engagement and health information exchange. As such, it’s important to remember that patient engagement is key for the future of HIE, agrees Gilman. “It’s actually critically important because the current meaningful use requirements have really driven patient portals to be developed practice by practice. The ultimate result is we’re going to have silos of patient portal information that are really confined to an individual system or practice. Leveraging patient portals through an HIE allows the patient to have access to information that cuts across the entire care coordination team that they work with.”

Moreover, according to Nagpal, the four considerations on every CIO’s and CMIO’s mind are how to reduce avoidable errors, how to improve outcomes, how to improve operational efficiencies, and how to manage the rise in costs. To accomplish these goals, he says, one thing is clear: more interoperability will be needed. The biggest successes are being achieved by provider organizations that are doing interoperability for their own patient population and their own referral networks, and are invested in a deep model in interoperability, making information available across all venues of care. That enables physicians to proactively respond to patient conditions before a patient gets sicker, and do population-based analytics, he says.

The success of ACOs, patient-centered medical homes (PCMHs), and bundled payments all will be reliant on interoperable HIE systems across the entire continuum of care, agrees Gilman. “In order to have meaningful service delivery and payment reform models, you need to have greater coordination of care,” he says. “To support quality and efficiency initiatives, you need good data. Over the last few years, our HIEs have really focused on getting providers connected; but now, in Texas and across the nation, the focus is on more advanced forms of HIE including notifications and analytics to support better health outcomes. That’s the real value in HIE, and why I see it as the cornerstone of healthcare transformation.”

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