Study Finds that Public HIE Efforts are Declining as Researchers Question Their Long-Term Viability

July 8, 2016
The number of community and state health information exchange (HIE) efforts—either in operational or planning mode—is declining, leaving the viability of broad clinical data exchange uncertain, according to new research in the July issue of Health Affairs.

The number of community and state health information exchange (HIE) efforts—either in operational or planning mode—is declining, leaving the viability of broad clinical data exchange uncertain, according to new research in the July issue of Health Affairs.

To assess the current landscape, the researchers—led by Julia Adler-Milstein, Ph.D., assistant professor in the School of Information and School of Public Health at the University of Michigan—set out to conduct a national survey of community and state HIE efforts soon after federal funding—which began in 2010 to the tune of $600 million across the country—ended. The researchers have done a similar survey on HIEs approximately every other year between 2007 and 2012.

The study found 106 operational HIE efforts that, as a group, engaged more than one-third of all U.S. providers in 2014. However, the number of operational HIE efforts is down from 119 in 2012, representing the first decline observed since the tracking of these efforts began in 2006, the researchers reported. “Only half of operational efforts reported being financially viable, and all efforts reported a variety of barriers to continuation. These findings raise important questions about whether the current vision for HIE efforts will allow for the broad exchange of clinical data, or whether alternative approaches would be more successful,” they concluded.

Dr. Adler-Milstein and her team sought out to survey all community and state organizations in the U.S. that facilitated the exchange of clinical data between independent entities as of December 2014. The final sampling frame consisted of 202 potential HIE efforts, of which eventually got reduced to 127 respondents. To be consistent with previous years’ research on HIEs, the study did not include HIE networks led by single electronic health record (EHR) vendors or a consortium of vendors, such as Epic’s Care Everywhere Network or the CommonWell Health Alliance.

For the study, the researchers calculated the numbers of operational HIE efforts (efforts that were actively exchanging clinical data) and efforts planning to become operational, and then compared these figures to those from surveys from previous years. They also looked at the number of operational HIE efforts that could enable participants to meet HIE-related Stage 2 meaningful use criteria, and the number of efforts that could support delivery and payment reform efforts, as well as the financial viability of these HIE efforts.


The results showed that that in late 2014, 106 HIE efforts were operational and 21 were planning to become operational. The number of planning efforts had declined 60 percent from the 53 that the researchers identified in their 2012 survey. The number of operational efforts had also declined by 11 percent from the 119 such efforts identified in 2012, they found.

Across operational HIE efforts, the researchers found that the most commonly reported stakeholders that provided and received data among inpatient settings were private medical and surgical acute care hospitals (providing information in 82 percent of the efforts and receiving it in 81 percent). Among ambulatory care settings, the most commonly reported stakeholder that provided and received data was independent physician practices (in 79 percent and 88 percent of efforts, respectively). Long-term care providers provided data in 40 percent of efforts and received data in 51 percent.

What’s more, test results and patient summary care records were the most common type of data exchanged (both were exchanged in 89 percent of efforts), followed by discharge summaries (exchanged in 78 percent of efforts). Alerts of admission, discharge, or transfer were the most common type of inpatient data exchanged (in 69 percent of efforts), and medication and problem lists were the most common type of data from ambulatory settings exchanged (in 66 percent of efforts).

Regarding Stage 2 of meaningful use, the study found that 77 percent of the operational HIE efforts could support the ability to transmit a summary-of-care record for patients referred or transitioned to another provider or setting. Sixty-three percent of efforts could transmit clinical laboratory test results as structured data. The two criteria least often met were supporting providers’ ability to enable patients to view, download, and transmit their health information and e-prescribing (34 percent and 16 percent of efforts, respectively).

Respondents were also asked to report whether they offered services to support delivery and payment reform efforts. Fifty-six percent of operational HIE efforts reported that they currently support accountable care organizations (ACOs) or similar efforts, and 55 percent reported that they currently support patient-centered medical homes. One-quarter of efforts indicated that they were planning to support reform efforts in the future, leaving only 6 percent of HIE efforts that were not currently supporting and or planning to support reform efforts, according to the research.

In terms of financial viability, 49 (52 percent) of the 94 operational efforts that reported on their financial status were financially viable, meaning that they could cover operating costs with revenue from participants. This percentage is significantly higher than the 24 percent of operational efforts that met this definition of financial viability in 2012 (28 of 119 efforts). An additional 9 percent of the efforts in 2014 were able to cover 75–99 percent of operating costs with revenue from participants; 10 percent of the efforts were able to cover 50–74 percent of costs; 6 percent were able to cover 25–49 percent of costs; 12 percent were able to cover 1–24 percent of costs; and 12 percent were unable to cover any operating costs with revenue from participants.

Developing a sustainable business model was the most prevalent barrier to HIE progress in both 2012 and 2014 (38 percent of respondents reported it as a substantial barrier in 2012, and 33 percent did so in 2014). This was closely followed by integration of HIE into provider workflow, a barrier that the researchers asked about for the first time in 2014.

The authors concluded, “For the first time since our survey began in 2006, we observed a decrease in the number of operational HIE efforts and a much larger decline in the number of efforts in the planning stage. This likely signals the beginning of a transformation, as federal funding is diminishing and new competitors to state and community HIE efforts are growing in number and size in the market.” They added, “Because there is no ongoing national public commitment to fund HIE efforts (though some states have provided their own funding), securing a robust base of paying participants is essential… Taken together, our results suggest that while HIE efforts have grown since the passage of HITECH, their long-term viability is still uncertain.”

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