HIE Models - Can’t we just get along?

We constantly hear in HIT news about RHIOs, state-HIEs, the Direct project, private (hospital or IDN sponsored) HIEs and now on the horizon – commercial HIEs. The newest controversy is about which model is best. But that’s missing the point.  We shouldn’t be talking about which one is best but how we leverage each form of HIE into a fabric of active healthcare information exchange – the verb not the organization.

A Historical Case Study

In the late 80s and early 90s, we had much the same controversy about email platforms. There was advocacy for America OnLine (AOL), MindSpring and multiple other Internet Service Providers (ISPs).  Then television cable and telephone companies began offering their versions of email service.  Each of these charged for the basic privilege of their customers to communicate with one another.  In those days, I had a MindSpring account for work, an AOL account for personal use and a cable account for an association I belonged to.  Each required me to pay a monthly fee to talk to a certain group of people because their systems didn’t communicate with each other.

Within a few years, standards were developed that allowed ISPs to exchange email across platforms.  Suddenly the value of the ISP sponsored email system as a communication device evaporated.  To keep subscribers, ISPs scrambled for a new business model with a different business proposition.  Some made it through that tumultuous period by adding value to products and reinventing their revenue streams.  Others, like MindSpring, established in 1994, went public in 1995, merged with EarthLink in 2000, tried to reinvent themselves in 2006 as a VoIP provider and disappeared from the marketplace altogether in 2008.

Still other entrepreneurs started new businesses to take advantage of new possibilities.  Hotmail, Gmail, Yahoo and others thrived by giving away email to gain market share adding calendars, instant messaging and other innovations for free.  Subscribers quickly jumped ship from pay-for-email to these reliable, secure and free providers who invented new revenue streams from marketing dollars.

Evolving HIEs

HIEs will go through the same growing pains as any other newly established industry.  However, we have reached a tipping point where the verb health information exchange outweighs the organizational health information exchange for two reasons.  First, the organizations have mostly been funded through grants, government subsidies or other start-up funds from the time of the CHINs, through the RHIOs and now the initial HIEs. We are now seeing hospitals, IDNs, communities and independent entrepreneurs define a need, design use cases, determine value propositions and distribute costs of the start-up and ongoing operation BEFORE they begin implementation.  Second, we see that HIEs  established years ago and that have now run out of grant funding reinventing themselves with different, more economical solutions because they recognize the value of exchanging health information. Even in instances where grant funded HIEs have collapsed once grant funding ended, we are seeing new organizations form with more sustainable solutions to backfill the need within those markets (for example CareSpark dissolving and Knoxville HIE forming).

Network of Networks

Just like email ISPs, I believe the first stage of evolution for HIEs is to become a network of networks.  This model will allow existing HIEs to reap the optimal benefit from each form of HIE today. The reason for this is that there are various value propositions for health information exchange (the verb) depending on the distance from the patient consuming care.  The majority of healthcare is consumed locally, therefore the need and intensity of data exchanged locally is much greater than passing information to the next community, state and/or to the federal government.  As you move further and further out from the locality of the patient, fewer transactions occur and they usually are much more specific in nature.  For instance, community-to-community exchange will usually be centered on individual mobile patients or referral patterns for specialty care; states would like to have immunizations, communicable diseases and other reportable events electronically; and the federal government needs quality reporting, disability determination and the like.  These transactions are periodic, specific and use case driven.  Therefore, each local HIE (if properly constructed) would act as a clearinghouse for the clinical data needed outside the community while providing a local neural network for local care delivery.  In this way, the hospitals, clinics and other healthcare entities would only have to connect to one HIE and that HIE would act as the distribution point to all the other HIEs in other communities, within the state and to the federal government.

Does this model leave room for Direct? Absolutely. Ninety percent of the United States’ geographic territory is considered rural with about 16% of its total population living there.  This population is generally underserved by healthcare professionals and those who serve this community often have lower margins than urban or suburban healthcare providers.  Therefore, using Direct protocols for communication of health data within this “white space” and between this white space and urban HIEs will increase data flow, improve care and reduce costs without a large outlay of dollars for infrastructure.

Commercial HIEs

Extrapolating from the email case study above, I believe the next evolution of HIE will be a commercialization of sponsoring organizations.  Entrepreneurs will begin to seek out value propositions, use cases and revenue models to fill the needs across the country.  Like ISPs of the past, these organizations will partner with a solid infrastructure vendor and build value based add-on services and tailored solutions using the health information exchange infrastructure as simply a vehicle for value distribution.  These organizations will break through the barriers of governance, policy and data sharing agreements stifling many 501c3-based HIE organizations by offering a standardized, non-political structure within which to bring cost efficiencies and care effectiveness to the healthcare system.


At this point in HIE evolution it is necessary that we do not discount any HIE model because the HIE industry is in its infancy.  The important decisions at this stage is to have an infrastructure that can meet legacy requirements, existing standards and has the flexibility to adapt to change so that whatever happens to the organizational structure of HIEs a complete overhaul of the pipes is not required.

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