The numbers are daunting. Nearly two decades after the advent of community health information networks and more than five years after the Bush Administration starting pushing for electronic health records and health information exchanges, only 28 states have one or more operational HIEs. And operational doesn't mean everyone in a region, much less a state, is active in the HIE.

In a nation of 300 million residents over 3.5 million square miles, there are 193 HIEs in various stages of development, according to eHealth Initiative, a Washington-based industry advocacy organization. By self-attestation, 57 of the HIEs are operational. Most HIEs don't have a sustainable business model, and getting a critical mass of regional stakeholders to cooperate in exchanging their data remains an extremely difficult proposition.

There are other reasons that many observers say HIEs should not be relied on as an anchor of an eventual national health information network, the vast, interconnected system ballyhooed by the federal government. Some argue that a network tantamount in scope - namely, the network of claims clearinghouses - already exists and also could handle clinical transactions. Or, mandated use of data standards and the Continuity of Care Document, a standardized summary of care, coupled with a now-mature Internet infrastructure, could do most of the work that HIEs are supposed to do. In one state where several HIEs are developing, the government is helping fund tests of an alternative model, called health records banks.

On the flip side, fueled by several years of momentum, and recently $300 million in funding via the American Recovery and Reinvestment Act - plus matching state funds - the number of HIEs is growing. One hundred and fifty HIEs responded to eHealth Initiative's survey this year, up from 130 in 2008. The organization then confirmed that 43 HIEs that responded to the 2008 survey but not this year's were still functioning for a total of 193. The 57 reported operational HIEs this year that are actually delivering test results, care summaries and other information was a 36% increase from 2008, which was 31% higher than 2007. And in 2009, 67 HIEs responded to the survey for the first time, compared with 18 a year earlier.

Further, a wide range of HIE models have emerged to meet local needs, and there are several established and proven models to copy. HIEs exchanging laboratory and radiology reports, and outpatient and emergency episodic data, increased significantly in the past year, according to the survey. And hospitals increasingly are realizing that better communication with physicians is good health care and good business, and HIEs can help them link with physicians.

So, does reliance on HIEs to form the network-of-networks mean a national health information network is doomed to fail? Or, are HIEs progressing at good speed and proving to be the model that will work? The Obama Administration, embroiled in deliberations to develop rules that will govern its national health I.T. strategy under ARRA, did not respond to requests to interview Chief Technology Officer Aneesh Chopra and David Blumenthal, M.D., the National Coordinator for Health Information Technology. For others, let the debate begin.

Lay of the Land

Consultant Michael Mytych is a wary proponent of HIEs. "I believe the HIEs can play a very important role, but if they're not set up and are not properly funded, we'll be in big trouble," says the principal of Health Information Consulting LLC, Menomonee Falls, Wis.

Mytych calls the data exchange work already being done in regions across the nation "the Wild Wild West of HIE." The different initiatives are trying to do the same thing, only in a hundred different ways. Asked if HIEs are the right or wrong road to a national network, he adds, "We'd better come to a conclusion pretty quickly because with 193 HIEs out there, there's a lot of money being spent."

For a national health information network to succeed, HIEs need uniformity in handling patient identity and consent, content checking, the Continuity of Care Document and a host of other issues, he contends. "Some of them aren't even paying attention to the need in their own market for EHRs to exchange data with each other."

That's a real problem because Mytych doesn't see many HIEs offering the opportunity to exchange information in discrete data elements that can be uploaded into physician EHRs. And it still is not easy to pull data out of many hospital information systems. HIEs often make laboratory results, medication lists, patient histories and other information available in view-only mode. But if physicians are using this information as part of their clinical decision making process, HIEs have to find a way to get the data into EHRs, he says.

National HIE standards - not just for moving data but for policies such as handling patient consents and behavioral health records - are needed across the board, Mytych believes. He notes that the New York City region has multiple HIEs. "What if specialists have to participate in all of them? That's a lot of coordination to do."

A federal mandate to use a standards-based, machine-readable Continuity of Care Document would be a big step toward showing the value of HIE, Mytych contends. He believes another mandate is necessary but doesn't see policymakers willing to pull the trigger to make it happen. "If the government really wants a national health information network, it would have a national patient identifier. That itself would save billions of dollars."

A Working Model

After exchanging clinical messages for a decade, the HealthBridge HIE serving the greater Cincinnati region is proof that with the right business model, a regional effort can succeed.

Some 5,600 licensed physicians are in HealthBridge's service area. In a typical month, the HIE pushes 3 million lab results, transcribed documents and notifications of admission, discharges and ER visits to more than 5,000 of the doctors, says CEO Robert Steffel. Ninety-six percent are delivered electronically via e-mail, fax or an inbox on a portal. One-third of these 3 million messages comprise discrete data elements that go directly into the EHRs of 1,300 physicians.

Steffel recalls HealthBridge being built on the ashes of three failed community health information networks during the 1990s. Today's HIEs, he contends, are not yesterday's fatally flawed CHINS.

"When I look at what happened to CHINS, that was all about having a proprietary system with a vendor driving it," he notes. "But it turns out you can't buy collaboration from a vendor."

HealthBridge succeeded, Steffel says, because its fee-paying member organizations saw the business advantage of joining. "We were able to go to hospitals and have them outsource results delivery to us." He concedes that HealthBridge's model may not work in rural regions because of economies of scale. The biggest role that states can play in HIE initiatives, he adds, is to support rural connectivity.

Collaboration among stakeholders, however, remains elusive in many regions of the nation. Organizations want to see the clinical value and return on investment before joining an HIE, but the HIE needs enough early adopters to get to the point where it can show value and ROI.

Many HIEs still fail because good intentions aren't supported by a workable business plan, says John Osberg, president of Informed Partners, a Marietta, Ga.-based consulting firm. "You need a business reason that is the foundation for the initiative, and few of the HIEs I've seen have a business reason for being there," he contends. "I don't believe altruism will get you there."

Emerging HIEs need a focused effort to document return on investment, says Jennifer Covich, COO and Interim CEO of eHealth Initiative. And many HIEs need help doing that because the organizations are just trying to sustain themselves. "They don't have the resources to document ROI," she adds. "We need private and public support for documenting best practices and ROI. There are a lot of organizations out there that can learn from each other - they don't need to make the same mistakes." Stimulus funds, Covich hopes, will help accelerate HIE efforts and development of test beds so mistakes can be avoided.

Health Internet?

While the Bush Administration viewed HIEs as the base for a network-of-networks to build a national health information network, that view has changed in recent years. "It's not realistic to think you can just cover the nation with hundreds of disconnected HIEs," Covich says.

She believes, however, that HIEs can serve as a starting point and could help form the foundation of a national infrastructure. For now, HIEs are helping stakeholders figure out a myriad of issues - such as data ownership, access rights and security - associated with widespread health information exchange among disparate organizations.

Over time, Covich sees the nation developing more Web-based systems. The idea of using the existing high-speed Internet infrastructure as a "Health Internet" that continues to mature and is available to more areas of the nation is getting plenty of attention these days.

Two top I.T. officials of the Obama Administration, CTO Aneesh Chopra and HHS CTO Todd Park, in late September attended an invitation-only meeting in Boston with about 100 industry stakeholders. The officials floated the idea of a "Health Internet" to not only serve health care organizations but also consumers.

"They are focusing on messaging and application layers to allow the secure transmission of health information among stakeholders," says meeting participant John Moore of Chilmark Research.

A Health Internet would involve adoption of a standard service-oriented architecture, tailored to the health care environment, but similar to what's used on major online retail sites such as Amazon, Moore explains. A consumer placing a book order on Amazon, for instance, can track the status of the order and real-time shipping status via UPS from the Amazon site. To enable this, Amazon sends out a service call on behalf of the consumer to UPS. This service call - a query and a response by authorized users via the Internet - could be modified for health care needs, Moore contends.

Private and public HIEs would be some of the spurs that would provide data and potentially other services on the Health Internet. But the Health Internet won't have all pertinent information that is needed for clinical and financial decision making, quality and public health reporting, and other needs "for a long time," Moore says.

Dropping the term "national health information network," would help build understanding and momentum for a Health Internet, Moore says. "People can get their hands around the 'Health Internet.'"

Network Already Here?

Across the nation, claims clearinghouse and other electronic data interchange vendors each year electronically transmit billions of claims and related financial/administrative transactions among providers and payers.

Some of these organizations believe the national health information network already exists for financial transactions and that network also could move clinical transactions. "We're wanting to get the message out that we have the track record, connectivity and move millions of transactions a day," says Doug Bilbrey, president of The Cooperative Exchange, a consortium of 12 such vendors. He's also executive vice president at The SSI Group Inc., Mobile, Ala.

Cooperative Exchange members believe the health care EDI network could be the anchor for a national health information network, Bilbrey says. "We believe the infrastructure is built, and it's an industry able to do it now. We have the connectivity and standards in place, we simply need to do it."

Policymakers and health care stakeholders need to make a national network a simple process, and that's what EDI vendors offer, Bilbrey contends. "I don't care what your records look like as long as they can be packaged in a communications protocol and read by the receiver."

Right now, policymakers are unaware that such national connectivity is "right under their noses," Bilbrey contends. He acknowledges that there hasn't until recently been a grassroots advocacy effort by EDI vendors. "Most of us don't have lobbyists in D.C.; we see ourselves as service providers."

Members of The Collective Exchange are starting to reach out to members of Congress and others to get their message heard. "We're optimistic that at some point, we'll get to someone in a policymaking position who will realize we don't have to start at the beginning," Bilbrey says.

Cambridge, Mass.-based NaviNet Inc. is not a member of The Collective Exchange but supports the effort to raise the visibility of EDI vendors. NaviNet in August sent letters to the governors of all 50 states offering to make its NaviNet Health Information Exchange network - a recent modification of its existing EDI network - available at no cost to state HIEs and regional ones that are state-designated entities. The company would generate revenue via transaction fees paid by HIE users. A month after sending the letters, the company had received responses of "active interest" from several states, says Brad Waugh, CEO.

NaviNet offers Web portals to health insurers to enable providers to conduct such electronic transactions as eligibility, referral and claim status. Insurers pay the transaction fees. The company doesn't seek to replace HIEs, but to provide complementary services that states can implement quickly and at no cost to bring immediate value to HIEs. "We provide transaction sets to help providers get paid," says Del Richmond, marketing manager.

The Hard Part

HealthBridge's Robert Steffel has been impressed with the Obama Administration's health information technology strategy and the massive amount of stimulus funding that goes with it. "There has been a focused, diligent and honest effort to figure out how to do this and do it well." But Steffel doesn't believe all the money will be spent well. "HIEs are very hard to do. Money's not the hard part; it certainly is a barrier, but collaboration is the hard part."

Others say it's too early to know whether the money being thrown at HIEs and other I.T. initiatives will be well spent. "My concern is there's a lot of money going into the system very quickly and the system isn't used to that, so there's a lot of opportunity for mistakes to be made," says Moore of Chilmark Research.

For NaviNet's Del Richmond, $300 million is good seed money for HIEs, "but if you're at Ground Zero you'll exhaust most of it on planning before you have anything. So the jury's still out on how wisely that money will be spent."

Covich of eHealth Initiative notes that some emerging HIEs that are angling to receive stimulus funds to become regional extension centers. Most are not prepared to assist providers in adopting EHRs, she contends. "An organization in the early planning phase would not be able to do this. But there is a small group of advanced, operational HIEs that are equipped to do this and could do it very well."

This article can also be found at HealthDataManagement.com.