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HIEs in the Public Interest

by John Moore | July 29, 2010

The Health Information Exchange (HIE) market is the Wild West right now.  Vendors are telling us that they are seeing an unprecedented level of activity both for private and public HIEs.  Private HIEs are being set-up by large and small healthcare organizations to more tightly align affiliated physicians to a hospital or IDN to drive referrals and longer term, better manage transitions in care in anticipation of payment reform.  Public HIEs are those state driven initiatives that have blossomed with the $560M+ of federal funding via the HITECH Act.

But this mad rush is creating some problems.

While the private HIEs seem to have their act together in putting together their Request for Proposals (RFPs), such is not the case for the state-driven initiatives.  Rather then formulating a long-term strategy for the HIE by performing a needs assessment for their state, setting priorities and laying out a phased, multi-year strategy to get there, far too many states are trying to “boil the ocean” with RFPs that list every imaginable capability that will all magically go live within a couple of years of contract reward.  Now it is hard to say who is at fault for these RFPs, is it the state or the consultants they have contracted with that formulated these lofty, unreachable goals, but this is a very real problem and unfortunately, the feds are providing extremely little guidance to the states on best practices.

While the above is more of a short-term concern, longer-term we may have a bigger problem on our hands.  The proliferation of private HIEs, coupled with state-driven initiatives with very little in the way of standards for data governance, sharing and use (this includes consent both within a state and across state lines) has the very real potential to create a ungodly, virtually intractable mess that will be impossible to manage.

So maybe it is time to rethink what we are doing before we get to far down this road.

What if we were to say, as a country, that much like Eisenhower did during his presidency to establish the Interstate Highway system, we made the decision that it is the public interest to lay down the network for an “interstate” system for the secure electronic transport of health information?  And rather than be cheap about it as we have done in the past dedicating only modest funding (e.g., NHIN CONNECT), let’s really make the investment necessary to make this work.

Yes, it won’t be cheap, but think of the alternative – 50 states, countless regions all with their own HIE.  Yes, states are required under HITECH to work collaboratively with neighboring states, but this will not lead to enough consistency to create a truly networked nation for the delivery of quality healthcare for all US citizens.

It is indeed time to take a stand for much like Eisenhower’s Interstate system, which I had the pleasure to enjoy as I traveled cross-country this week from Boston to my beloved mountains of Colorado, such an interstate system for the delivery of health information at the point of care will be something all citizens will benefit from. And taking a cue from the image above, rather than a “Symbol of Freedom” it would become a Symbol of Health.

8 responses to “HIEs in the Public Interest”

  1. Phil Pearl says:

    Absolutely. Right on the money.

    I have proposed to HHS that they provide a PHR system for use by all U.S. residents nationwide to avoid the user worries that exist with commercial products, such as how long they will be around, and the sale of private medical information for commercial gain / spamming.

    Such a PHR could be based on the MediRec PHR at http://www.medirec.org, could be set up at http://www.healthcare.gov, and might look like this :


    Keep up the good work with the research and articles!

    Phil Pearl

  2. […] Article John Moore, Chilmark Research, 29 July 2010 SHARETHIS.addEntry({ title: "HIEs in the Public Interest", url: "http://articles.icmcc.org/2010/07/30/hies-in-the-public-interest/" }); […]

  3. Brian Ahier says:

    You raise some important issues John, and make some great points. I think that HIE could become a significant barrier to future phases of meaningful use unless a more cohesive national strategy is developed.
    I am still cautiously optimistic…

  4. Mark Frisse says:

    I share your sense of the importance of the problem, but lean toward a more “emergent” approach based more on simple internet protocols and a few basic standards. NHIN Direct is a step in the right direction in my mind. (Using your analogy, I’d say the roads are largely paved in many regions but we lack common traffic regulations.)

    The challenge of HITECH is that it attempts to force cultural change with relatively small amounts of money when viewed per capita or as a percentage of health care expenditures. I look forward to more discussion on your site about this important matter.


    • John says:

      Hi Mark,
      Thanks for chiming in on this issue as I have a lot of respect for what you have done down in TN at Vanderbilt. Likewise, I am not in favor of the heavy top-down approach that has so often ended in failure in the healthcare IT market but especially with regards to health information exchange initiatives. The market is littered with so many failed attempts of this sort.

      That being said, I am likewise becoming increasingly concern with the lack of cohesion and direction by the feds as it pertains to the multitude of HIE initiatives, both public and private that are blossoming like mushrooms after a summer’s rain. Without that guidance, we could be left with quite a morass. NHIN Direct is one initiative by the feds that shows promise, but it only addresses a very discrete issue of information transport and HIE, as you know is far more complex than this one issue.

      Also, part of my argument is that we as a nation may wish to simply view this whole issue of health information exchange for care coordination in a different light and like the interstate highway system, put in that infrastructure as part of the good for all citizens, rather than the seemingly haphazard approach that has been taking to date.

  5. Mark Frisse says:


    The more recent comments raise another issue. How does one accelerate the emergence of a new market? And this is a new market. There are different notions of what the product is and how to make it available. There is no agreement on value; both buyers and sellers are trying to figure this out.

    New markets take time to emerge (think Internet commerce). Federal action can help, but only to a limited extent. In my own view, given the legislation, ONC is doing a good job; but the emergence and coherence will take time despite the best efforts and intentions.


  6. John,
    Not sure I agree with your premise. From what I’ve seen of EMRs and especially HIEs, there is very little clarity around what they actually “do”.

    There is very little operational proof that multiple entities can trade anything outside of reports and that the information in the reports is either accurate or useful in reducing error, changing behavior, or improving population management (which are the ultimate goals).

    My personal sense is that HIEs in the current HL7/SNOMED/ICD10 world where billing volume matters more than outcome improvement is just as likely to serve to lock in unhelpful metrics from an outdated (FFS) approach than actually create value.

    I would ask that we step back and make sure we know where we’re going before building the superhighway…there’s a reasonable chance that what’s being built right now may just be a bridge to nowhere….

  7. Mark Metzler says:

    Here is a useful new website you might want to consider:

    Biomedical Device Integration Tech Corner

    “An archive of technical documents, protocols, standards and procedures useful for clinical engineers and IT professionals involved in biomedical device integration and connectivity to electronic medical records (EMR)”

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