HIEs Need Cultural “MegaChange” to Flourish

The alchemy involved in developing and executing successful health information exchange (HIE) is complex.  Technology, policy and specific organizational situations are core components embedded in the success/failure equation that can either help or hinder the creation of a thriving clinical data-sharing network, whether in a hospital, IDN or region.  Because HIE, by definition, requires the cooperation and coordination of multiple groups factions and individuals within an organization, it is important that the various agendas of these groups be identified and addressed.

A recent White Paper published by the Brookings Institution on the governance of HIEs finds that implementation challenges and barriers to successful HIEs are similar to the challenges found in setting up government programs because of the density and complexities intrinsically found in both. “Mission ambiguity, problems of organizational coordination, resource and organizational capacity restraints, political interference, as well as lack of clarity and consensus, limit the ability of policy makers to achieve the desired goals.”[1] Institutional and regional HIEs face these same issues, which are also further complicated by a heavy dose of technology which is at the heart of HIE and what makes it possible.

States and organizations that have implemented HIE are well aware of these challenges and all are in different stages of the throes of wrestling them to the ground to either start-up or improve the distribution and sharing of patient data. For example, Tennessee, an early adopter of HIE, has chosen to build an HIE network on the foundation of former RHIOs (regional health information organizations). This approach has the advantage of embedding interoperability into an existing structure between organizations. The state leverages a “network of networks”[2] methodology of using already accessible networks at the local and regional levels to provide a universal layer of connectivity.

This approach has worked very well for Tennessee, whose HIE is a public-private partnership comprised of physicians, nurses, pharmacists, hospitals, insurers and patients. Other states have had similar, as well as a host of other issues, to deal with.  Among them are 1) governance mechanisms which have a huge effect on implementation. These players typically include hospitals, medical societies, government health departments, universities, physicians and public officials. Others often include payers and unions. The number of players, all with varying agendas, makes implementation a tremendous challenge; 2) consensus on the path forward. With many aspects of healthcare reform being contentious, tensions inevitably arise between local, regional and state organizations which further slow down implementation; 3) the role of the federal government which includes the Direct Program designed to effect simple and secure clinical messaging. While Direct’s goal is to connect many physicians and hospitals, many claim that the program undermines efforts to connect at broader levels.  And demand for Direct protocols, thus far, has been weak. 3) privacy and security continues to complicate HIE performance since data exchange requires permission and consent.  Uncertainty about privacy can greatly impede, if not kill, an exchange network unless sufficient guidance is made explicit. And finally, 4) the elephant in the room is sustainability. With HITECH funding not being eternal, HIEs must plan for ongoing self-sufficiency.  This inevitability is complicated by the current weak economy with states still cutting budgets. Options being considered are membership or subscription fees along with a small “claims tax” which will enable sustainability.

In short, HIEs, while in many ways the clear answer to the kind of connectivity that will ultimately reduce healthcare costs and improve outcomes over the long haul, face daunting challenges. These challenges, taken as a whole, are probably best addressed through a cultural shift, or MegaChange in attitudes that will enable the tackling of these issues broadly in order to get us where we want and need to be: the transformation of healthcare delivery in the U.S.


[1] Kent Weaver, “But Will It Work?: Implementation Analysis to Improve Government Performance,” Issues in Governance Studies, February, 2010, pp. 3-8.

[2]  Darrell M. West and Allan Friedman, “Health Information Exchanges and Megachange”, Governance Studies at Brookings, February 8, 2012, pp 20-21.