In about 2004, the concept of a regional health information organization (RHIO) began to proliferate, says Lynn Dierker, R.N., director for the State Level Health Information Exchange Consensus project at AHIMA/FORE. Now there are probably over 100 RHIOs.

But, particularly over the last year, there has been a movement toward state-level activity and, specifically, state health information exchanges (HIEs), Dierker told a recent meeting of a State Alliance for e-Health subgroup.

Over 30 states are doing various things on HIEs, says Dierker—who formerly served as the interim director for the Colorado RHIO and director for community initiatives—however only a minority of them currently have exchanges they consider state-wide. The total count of those state HIEs is a moving target, she says. But, as one indication, there are 11 states with exchanges on the steering committee of her project, which is supported by the Office of the National Coordinator for Health Information Technology (ONCHIT).

But there is wide variation even among those exchanges, she points out. Some have a statewide mission, but are starting with less than statewide exchanges. Others are focused on knitting together activities that already exist regionally.

Tennessee, for example, has three very different regional exchanges and a state-level coordinating entity. The Rhode Island Quality Institute, which has existed for several years, is building a state health information exchange as part of its work. Colorado is building an "index" that links diverse data sources to make records available to providers, according to Dierker.

What's motivating the focus on states? Governors, state legislatures and agencies have a growing interest in HIT as a necessary piece of reform, says Dierker. They believe that better information is critical to avoiding mistakes and inefficiencies.

There is still debate on sundry questions such as how to wire states together and how to connect nationally, or how many RHIOs are needed, or if RHIOs are needed at all. But, she indicates, there is a strong sense that the state, as a geo-political unit, "is going to be there and it has some particular issues about representing populations," and also has important interfaces with policies, laws and programs, such as Medicaid.

The project on state-level exchanges, housed at AHIMA, will issue recommendations and discussion papers over the next few months on best practices for state HIEs and will hold a consensus conference in November. A basic question, Dierker says, is "how you would knit together coherently an infrastructure that might include a collaborative public-private governance at the state level with any number of health information exchange operations."

On the other side of the coin, Gerry Hinkley, an attorney with extensive HIT experience, notes that not all attention is flowing to the state-level. He points out that RHIOs are still forming and evolving. Also, he says, attitudes about cooperation vary and large hospitals or systems sometimes are not motivated to share their data.

But, one way or the other, Dierker indicates, hospitals need to participate in the discussion on what state-level governance partnerships, as well as partnerships across state lines, will mean for them.

And in terms of getting a critical mass of participation, she indicates payers may be key in getting reimbursement to support cooperation.

Certainly ONCHIT's focus is on state coordination and several of its other sponsored activities are reaching milestones. The office is seeking to fund several states in trials on coordinating with a national network. Meanwhile, a lengthy review of 34 state HIT plans has found that much research is still needed on privacy and security issues, including differences in laws, the technology and processes. Reports are at, http://www.healthit.ahrq.gov.