At a time when the broad survival of health information exchanges (HIEs) is in question nationwide, and a number of statewide HIEs are shutting down or in danger of doing so, a small number of such organizations are actually flourishing, among them statewide HIEs in Maine, Michigan, Ohio, Texas, and Colorado.
As noted in the January/February issue of Healthcare Informatics, in the Top Ten Tech Trends cover story package, in the Trend article on HIE sustainability, leaders in those states have created success, even as other HIEs, both statewide and regional within states, have faltered, in the wake of disappearing federal and state funding for HIE development. What was clear in interviews with the leaders from successful HIE is this: that many of the statewide and regional HIEs created with wonderfully high-minded intent, but without a hardheaded business focus on long-term sustainability, are finding it difficult to make ends meet as the grant money begins to wither; but also, that those leaders who have figured out strong strategies for market-based success, are forging ahead and building new models.
Greg McGovern, a director at the Pittsburgh-based Aspen Advisors consulting firm, and a former health system CTO, spoke late last fall with HCI Editor-in-Chief Mark Hagland regarding the current trends in HIE development and sustainability. Below are excerpts from that interview.
When you look at HIE sustainability right now, what kinds of models will prove to be successful?
It’s a little Darwinian, right? If you look at healthit.gov, you’ll see that virtually every statewide HIE has some functionality. But the more successful HIEs are of two types. Of course, there are the enterprise-based HIEs, many of which, like those at Kaiser Permanente, Adventist Health, and Mary Washington Healthcare in Virginia, are showing very strong success; those are sustainable, because they’re built into the cost of business. And Epic’s CareEverywhere is a kind of EHR-based HIE. Then there are regional HIEs, such as HealthIX in New York City, and ConnectVirginia, and one in Cincinnati—they came on early and had sort of a subscriber model where the core players, the hospitals, primarily, agreed to support through subscriptions.
A great model is that of CliniSync in Ohio; so is the model created by HealthInfoNet in Maine. The thing is that, when states provide something, if all that they offer is a way to get stuff from point A to point B, that’s not very useful, because most organizations are able to do that through their EHRs. But if you’re going to offer other services, or direct functionality to long-term care services, for the transmission of continuity of care documents, for example—people will pay for those kinds of things. So folks are coming up with very imaginative, value-added services.
Is the exchange of CCDs [consolidated clinical documents] one example of practical, useful exchange?
Yes, it is. Not every organization has an EHR [electronic health record]; I’m thinking in particular of SNFs, long-term care facilities, and other organizations, none of which are required to have an EHR. And yet the physicians affiliated with those organizations will need to exchange patient data with the physicians in hospitals and medical groups. So hospital-long-term-care collaboration is a very good example of where the ability to exchange CCDs is something that is very useful in an HIE context. You can offer clinicians a mail box, basically, so that hospitals can send you a summary of care or transition of care document, and you can do the same, so you can collaborate with folks without a full EHR.
That’s where the potential is?
That’s what you see people offering. I was involved in the groups figuring out what the service was for California; and one of the things they do offer is direct messaging; and that’s probably the key ingredient for care coordination. How do you monetize that, though? Going back to Mary Washington in Virginia, a lot of times, the big person on the block like the hospital or integrated delivery network offers to the long-term care facilities, for free, HIE services, or subsidizes it. And I’m not sure that works on a state level. What you’ll see, is that some states are offering robust services and way beyond just sharing documents back and forth. Others, like California, are offering minimal services. And in New York and other places, they’re working to help providers lower costs. If I’m a hospital and already have to send reportable events and syndromic surveillance or registry information, to public health, that’s already set up. And ConnectVirginia can offer to be a broker at lower cost. So there’s some savings in moving to an organization paying for it.
What is Darwinian, though, it’s that it’s kind of like the ISP wars of the 90s—everyone was an ISP, and everyone offered you an e-mail box, but now it’s down to one or two carriers. So you’ll see convergence, but the more likely sustainability model is regional, in that organizations tend to revolve around communities in their markets. So when you see a regional HIE come up, as in central New York state—generally, it’s on a regional or community basis. So if you manage a logical region, there’s generally more value, and you’ll stick around as a player. And Maine is like that; it’s a regional HIE. It’s a fairly small state, and everybody in Maine works with each other. Larger states aren’t like that.
So the real sustainability will continue to be on the local level?
Yes, except in the cases like HealthIX and others where they’re working with state governments that are putting line items in their budgets for sustainability, usually to provide specific services like a patient portal. So, yes, state funding. But at the end of the day, you have to go around and talk to actual people like a hospital CIO and say, if I could do this for you, would you pay me for it? And they’ll say, well, either I’ve got Epic or can do this for myself; or, yes, and I’ll pay a subscription for it. Those have the best likelihood of continuing.