States will bear much of the burden for fulfilling President Obama's prescription of an electronic health record for every American by 2014.

Meeting that objective "is quite an ambitious goal," said Jodi Daniel, leading off yesterday's meeting in Washington, D.C., yesterday of the State Alliance fror e-Health. "We have a lot of work to do."

Daniel directs the policy and research office of the Office of the National Coordinator for Health Information Technology. The ONC supports the Alliance through a contract with the National Governors Association in an effort to assist states with their health IT initiatives.

John Thomasian, director of the NGA Center for Best Practices, said the onus will be on states to create a "network of networks" that will constitute a national health information network.

States will have also responsibility for enforcing privacy rules and establishing sustainable business models that will "allow [NHIN] to flourish over time," Thomasian said. "What is not quite clear is who will build the exchange and with what monies." Although the American Recovery and Reinvestment Act of 2009 appropriates $300 million for regional efforts, "hopefully that is a floor," Thomasian said.

States must choose the public governance model that will provide necessary oversight and funds needed to sustain an emerging health information exchange industry. Results of a NGA-sponsored study, released at yesterday's meeting, laid out three basic models for how states might manage health data networks. The report, titled, "Public Governance Models for a Sustainable Health Information Exchange Industry," is available on NGA's Web site.

At one end of the spectrum, states would have a direct role in building, managing and sustaining health information exchange infrastructure. They would be "responsible for it all," said Thomasian, including performance, privacy, security and financial sustainability.

Such an approach could, "serve as a basis for broader health care reforms in some states, as it represent the infrastructure necessary to collect the information needed to develop these policies," the report noted.

The do-it-all approach might be most attractive in places with the least mature markets for HIE technology. Likely drawbacks of this model include complex financing issues and slow adoption of new technologies.

A second model would treat IHE infrastructure like a public utility with strong government oversight. This option would be attractive, the report concluded, "in states where there is significant traction of private-sector electronic HIE efforts but limited coordination or concern over the sustainability of the existing efforts."

Attributes of such a model include familiarity, private-sector investment, sustainability and the recognition of health information exchange as an industry.

Thomasian encouraged meeting participants to think of this paradigm as the "power plant" option, noting that the Departments of Health in Rhode Island and New York are adopting similar structures.

The third model contemplated by the report is a health information exchange led by the private sector, which would make significant investments and be in a position to respond quickly to new technologies. Under such an arrangement, state government would be a stakeholder and collaborator.

The downside is that "in the absence of state government representation, there is the chance that specific populations, such as the low-income, high-risk population covered by Medicaid or specific public health program will not be appropriately represented in electronic HIE efforts."

Regardless of the governance models that they choose, states must move quickly to keep pace with the president's agenda.

"Health care reform cannot wait," said the president in his first State of the Union address yesterday evening, delivered a few blocks from where the State Alliance had met. "It must not wait, and it will not wait another year."