To describe the still-nascent collection of health information exchanges in the United States as a "patchwork" is rather an understatement: Sometimes it's more of a crazy quilt. There are public and private exchanges, large and small, and state, regional and local HIEs – all in various stages of completion.

Still, more and more providers – if perhaps hesitantly – are opting to enter into this at times confusing thicket and avail themselves of the cost-saving and care-improving opportunities provided by health information exchange technology.

There will be more to come. With anticipation that there will be more requirements for sharing of data through a health information exchange in meaningful use Stage 2, "hospitals essentially will have to participate in some HIE," says John Hoyt, executive vice president of HIMSS Analytics.

But many have still yet to dip their toes in the water. "They are so focused, right now, on internally getting the systems up that meet Stage 1 meaningful use, that I would suspect that's what's driving this 55 percent [of hospitals] that say, 'Nah, not doing it yet,'" Hoyt says, noting that "ICD-10 has probably got them running scared."

But there are glimmers of encouragement. Hoyt says he's "kind of surprised, frankly," to see the robust adoption numbers for hospitals with 100 or fewer beds. He reasons there are many small hospitals that are owned by bigger hospitals. "Maybe they're doing an HIE with a bigger hospital, running it out of that hospital's data center."

On the large hospital front, Pam Matthews, RN, senior director, Regional Affairs at HIMSS, points to another trend in information exchange that's 
"very progressive right now," in which integrated delivery system or large hospital networks that exist in multiple states are "calling themselves an HIE." It's a business model," she says, that's "a lot easier in many ways – in that you're not having to deal with the sustainability issues, and some of the others challenges you need to with a RHIO, but it's still an HIE."

Hoyt recently paid a visit to a system, composed of 43 hospitals in 10 states, that "really impressed me with their HIE maturity." Their strategy, he said, "made absolute sense to me. They said, 'we are not going to be mature enough to exchange outside of the organization if we can't exchange inside. So we're going to fix the inside first.'"

Providers within the system are running on a hodgepodge of different EHR vendors – Cerner for the hospitals, and everything from Allscripts to eClinicalWorks to Greenway for their ambulatory clinics. Getting all those to communicate seamlessly was a crucial task to start with.

"They fixed themselves internally first, with the practices they own, and now they're looking externally and going public," says Hoyt. "That way, they almost don't have to worry about the business model: If the [funding for the] HIE fails, they've still got their own sort of private network."

Of course, most hospitals couldn't imagine dealing with information exchange on that scale. The majority will be happy with a much humbler approach. Hoyt has some advice for those considering getting onboard.

First is to read up and "become very aware and knowledgeable of the standards," he says. Second, of course, is "be in the position to have something to share – which is what I think [most providers] are working on right now." Once an organization is in that position, its time then "to be able to fund the software development work to start sharing data – and make it an enterprise strategy."

Hoyt expects to see more adoption. By this time next year, the percentage of hospitals participating in HIE ought to be "in the high 40s," he says. "And the [14 percent of] hospitals that don't participate, but plan to, would probably be in the 20s," he adds. "Because they've now got their inside fixed up, so they can focus on and have a little funding for an HIE."

Money matters
HIEs are up and running. How long can the funding last?

Federal and state governments, hospitals and philanthropic groups can't keep holding the bag on health information exchanges forever.

"At this point, the real issue is the long-term sustainability," says Hoyt. "That's the issue, frankly: the business model. … I don't know if the government wants to be in the funding business of this forever."

Which exchanges will still be thriving in coming years? Ideally all of them. But, realistically, there will probably be some cash flow casualties. "I think time will tell," says Matthews.

Initial HIE grant funding "started coming out very quickly," she says, but of course it was never meant to be inexhaustible.

For a state "where there was not a lot of uptake of HIE, that was a way to kick off the process," says Matthews. "Or if you already had a state like Florida," where information exchange was well under way, the money could "continue to fuel that process that had already started and advance [HIEs] even further. But I don't think anyone thought that amount of money was a consistent revenue stream."

Hoyt has one solution to suggest. "Who benefits from this thing? Fundamentally, in the long run, the benefit goes to the payers. The payers should have motivation – one would think – to keep these things afloat." Reducing duplicate testing on a large scale saves an awful lot of money after all. "The big boys are in Washington, D.C.," he adds with an audible wink. "Are they going to continue to fund this thing?"
– MM