In the five years since the HITECH Act brought funding for public health information exchanges, the technology and the organizations that offer it have seen a varied evolution. Today, HIE as a whole is at a crossroads, with much of the public funding running out, but health data exchange services are more important than ever.

"The current landscape in health information exchange around the country is a bit disjointed, because the cooperative agreement programs have wound down now," said Brian Ahier, a long-time healthcare technologist who recently took a job as director of standards and government affairs at Medicity, Aetna's population health and HIE business.

"We're looking at a number of public HIEs that are in some cases sort of scrambling for business models that are going to carry into the future. The jury is obviously still out on the long-term prospects of a lot of these organizations around the country," said Ahier. "I think you're going to see over the next couple of years that those HIEs that are providing value to their membership, to the hospitals and physicians that need to share information, are really going to succeed."

A number of public HIEs have already shut down and there's a lot of pressure on other HIEs to increase their value proposition for providers physicians, payers and, if they're publicly funded, state governments.

In the Southwest, the Arizona Health-e Connection, a regional extension center and HIE organization, recently released its "Health IT Roadmap 2.0," outlining a course for the next three years, with funding from the Arizona Strategic Enterprise Technology office to help health organizations statewide pursue the "triple aim."

The non-profit's HIE, Health Information Network of Arizona, now includes 37 health organizations, including large and small hospital systems representing about half of the state's hospital beds, community health centers, health plans, two large reference labs and two county correctional centers. With clinical information on 3.5 million patients, the HIE covers about half of the state's population.

"While good progress has been made, there are still challenges and choices to address, especially as it relates to statewide health information sharing," said Melissa Kotrys, CEO of Arizona Health-e Connection.

Two challenges the organization is hoping to tackle and make headway on with stakeholders are at once "intricate" and "at times controversial," as Kotrys, a former Deloitte consultant, said.

"One initiative involves interoperability and content standards agreement and adherence that will develop and implement plans that ensure a national standards-based approach that facilitates and improves semantic interoperability. Another, a statewide unique patient identifier, will take on a topic that has seen some controversy on a national level," wrote Kotrys in a recent perspective piece for HIEWatch, a sister publication of Government Health IT.

"While we don't know where our work on a unique patient identifier will lead and if Arizona stakeholders will determine that a unique patient identifier approach is the solution to the myriad of patient matching issues, it clearly is an issue that must be addressed," Kotrys wrote.

For health information exchange broadly, at the local, state and national levels, the same is true: it's not clear where they will lead, only somewhere other than the status quo.

At Medicity, one of the largest HIE technology providers, about 20 percent of the business is devoted to public exchanges, including statewide HIE services in Vermont, Ohio, Colorado and Delaware and a number of regional organizations, said CTO Ashish Shah.

For both public and private HIEs, Shah said, Medicity is seeing some overlap in demand for certain services.

"For a state like Vermont or Ohio or Colorado, they are being approached by health plans or managed service organizations that are interested in learning about things that are happening to patients that they are responsible for proactively managing," said Shah, a former enterprise architect for an independent consulting firm that eventually was acquired by PricewaterhouseCoopers.

Those health organizations are approaching the states and HIEs, asking: "'If we give you a list of our members, any time that they happen to move in and out of a hospital or have a certain procedure done, can you push me an event notification, so that I can start to proactively manage their care as they move through the healthcare system?'"

Today, absent real-time clinical HIE, that's often accomplished with claims information. "The challenge with that is your typically waiting 30, 60 or 90 days for the claim to be processed, so all of the analytics in that care management group use inside of a health insurance company is dated; you're waiting a long time to intervene potentially," Shah said.

Over the next five years, HIE organizations as they are known today may be quite different, some perhaps fading away as EHR interoperability advances at a regional level and others moving into new services, like cancer registries that support research. But the demand for exchange will remain, and be just as crucial for primary care providers, insurers and hospitals — who are all going to be held more accountable for the quality of the patient experience.

"We are going to be working to move the market to a more instant network experience, where you're not working through terribly complex IT projects to get individuals or organizations in healthcare rapidly connected and collaborating," as Shah said. "This needs to happen at scale faster."