Q: On the market side, what do you make of organizations like the CommonWell Health Alliance?

A: To me, that's a welcome and necessary development. In meaningful use Stage 1 there was something like 3,000 vendors or something, and then you narrow the set and now it's a thousand, or whatever it is. I could see that this is going to evolve in the market. What might be the way it could can play in the U.S. It'd different than Denmark, where the government is very strong in that economy. They can dictate the terms and then everyone has to follow. Among industrialized countries, the U.S. has the weakest federal government of all of them. So the government is not going to be able to do that much with this as we move forward.

In other markets you start to see coalitions form in the industry, where they themselves recognize the need to do this. I can imagine a world where you have Epic – huge gorilla – and eClinicalWorks, another big gorilla, and then they have their own vendor-specific networks where a lot of health information exchange actually happens within their networks. There's a ton of interoperability that happens there.

And then you have CommonWell, which is a group of vendors getting together. In some ways it's one of the negative developments of competition, in a way, because who are the companies in CommonWell? Well, it's everyone who has an interest in making sure Epic and eClinicalWorks don't conquer the world, right? That would be the game theoretic way of looking at that.

But the other thing you could imagine, though, is fine, whatever the motivations, what if we start to see this grow. And Epic continues to grow. They have a network, eClinicalWorks has a network. CommonWell brings together six, 10, maybe 15 vendors under their umbrella. And at some point, in the not too distant future, I have three networks and I can cover 70 percent of the market if I could get these three networks to talk to each other. Maybe the federal government helps facilitate that, or maybe on their own, they just decide, 'Well, we've done all we can do on our own networks.'

Like the banks, where they had the ATM networks – there was Cirrus, there was Yankee and there was NYCE – they had a bunch of those networks but at some point the banks got together and said 'It makes more sense for us to get these networks to talk to each other now, because we're not going to get anymore market penetration: I can't steal anymore from you, you can't steal anymore from me, so we have an interest in getting our networks to talk to each other.

I could imagine that happening. And maybe that's going to be a solution at least one part of our interoperability dilemma.

The good thing about that happening from the vendor side is that if you look at what CommonWell is doing, they're deeply embedding that stuff into their (EHR) workflows. The problem, as we've discovered, with some of these certification processes is, as well intentioned as they are, if you have a requirements process that comes from the outside – and in this case I'll just say the outside is CMS, as a large purchaser, that defines requirements with all best intents and all the best input they can get, it's almost certainly going to be wrong on some level because the market is so complicated.

And so you have things like Direct, or whatever it is, that get foisted on the industry without a whole lot … it's sort of a novel thing that gets introduced and then doesn't get incorporated: 'It came from the outside, and I feel like I have to do it, but I'm not sure if my customers want it. I'll do it because I have to, but am I going to fully bake it into the way my software works? Maybe not.'

The good thing about CommonWell and these others is that it's more from the bottom up: 'I'm going to base this on the need that I'm seeing now from the providers, who are saying I want this fully integrated and easy to use within my application.'

Its a really useful development because it helps to jumpstart this process innovation that, with Direct, we're sort of struggling with: we have the technology, but it's not yet baked into the workflow.

Q: What do you see ahead for health information exchanges – the nouns, not the verb? A lot of them aren't reaching the critical mass many thought they would, and are having trouble building a vision for long-term viability.

A: Yeah. (Sighs.) I was one of the ones who had higher hopes for them than our experience has borne out. My personal view is that most of them will probably go away. And I don't think that's a bad thing. We live in a market economy, and they're market actors just like any other market actors. And if they're not delivering value people are willing to pay for, they shouldn't try to hang around.

The bad news for them is that increasingly vendors are fueling the demand from providers to come up with health information exchange solutions. And they're not saying, 'I'll outsource all this to an HIE.' They're saying, 'If my providers are demanding health information exchange, I'm going to come up with health information exchange solutions. But I'm not going to assume there's going to be a nationwide network of health information exchange organizations that I'm going to have to rely on in order to interoperate with other providers or vendor systems in this community.'

That's how a CommonWell comes up. If you look at what they do, well, they don't do anything different than any of the health information organizations claim to want to do. But they themselves are kind of feeling like, 'We want to do it in a way that we can control and rely on for these critical functions, and not rely on these other organizations that may or may not be there, or are not uniform across the country. I've got the Indiana HIE, that's great, but I've got a national customer base, and I can't build everything according to what Indianapolis does.'

But that's not to say they're all going to go away. There are many places where they're completely sustainable. The Massachusetts Statewide HIE is completely sustainable and will keep going. Indianapolis, Cincinnati, Rhode Island, Albany, Buffalo, Rochester – all of those have fee-based customers who are paying to keep them going.