Our View: Where’s the Data on Health Information Exchange

by Shaun Alfreds, Chief Operating Officer

“Despite $600 Million From Stimulus, Jury Out On Health Information Exchanges” read a recent headline from Forbes. Not the kind of news a health information exchange organization like ours likes to see.

The headline refers to yet another HIE study, this one from the RAND Corporation and published in the Annals of Internal Medicine. The study findings can be summarized as following: HIE use likely leads to reduced emergency room visits and related costs; the sustainability of HIE organizations is questionable; and, most notably, more research is necessary to understand how HIEs are used and their effect on patient care.

We agree. In order to quantify the value of HIEs and understand what will make them successful, we simply need more data. So if the government has spent $600 million on HIEs and, as the study authors report, there are over 100 HIE organizations across the country, why don’t we have the data? Well we have some thoughts.

  1. If you’ve studied one HIE, you’ve studied one HIE. The RAND study authors identified four distinct classifications of HIEs, and admitted that within these categories HIEs can be very different, making it difficult to draw any general conclusions. Yep! HIEs can be statewide, regional, city, or system based, public or private, use DIRECT or query functionality, share only lab results or complete medical records, send care summary documents or discrete data, offer added value services or not, and so on.

And what about usage? It’s also difficult to make generalizations about usage without knowing more about how usage is calculated. For example, at HealthInfoNet usage could be considered when an alert is sent by email, when a user logs into the clinical portal, when a report is run using our analytics product, or when a clinical message is sent in support of an ACO’s operations.

  1. Less impactful DIRECT (point-to-point exchange) has been promoted over more promising query HIE models. We believe the use of query-based HIEs will result in greater improvements in cost and quality than DIRECT. But query-based exchange requires time and trust building efforts involving competing community-wide stakeholders. Those query-based HIEs successful in leveraging the State HIE funds, began their HIE efforts long before the HITECH Act. When it became clear that comprehensive query-based HIEs would take longer and additional funds to develop, ONC pushed DIRECT exchange instead and wrote Meaningful Use measures to encourage it. As a result, query-based exchange was given very little consideration in Meaningful Use, making it a harder sell to potential provider customers.
  2. HIE grants did not contain directives or sufficient funds to roll out comprehensive evaluations. Only $600 million of the more than $32 Billion in HITECH funding was spent to start up or further develop State HIE interoperability efforts across the country. We can say from experience that starting and sustaining a query-based HIE takes significant funding. Here in Maine, the funds received through the HIE Cooperative Agreement program, while vital to our ability to expand, represented only a portion of the funds required to build the organization into what it is today. Operational HIE organizations funded through the HIE Cooperative Agreement program need additional funding to perform comprehensive evaluations of their usage and results.
  3. Lastly, HIE is still very new and adoption of any clinical tool takes time. Look at the history of the stethoscope. It took decades for it to be used widely and the current design has hardly changed in over 100 years. So for many HIEs, query-based or DIRECT, it is simply too early to quantify value because adoption takes time, and results take even longer.