Health Information Exchanges: One Solution to the Interoperability Dilemma


Everybody knows the struggle. Perhaps you’ve moved to a new city or changed insurance plans, but once again you’re having to change a majority, if not all, of your healthcare providers. Switching providers can be nerve-wracking enough especially after developing relationships with your previous providers, but now your new providers are requesting your medical records and history. A seemingly innocent and simple task is actually much more complicated than most realize. If your previous providers didn’t have patient portals, you’re stuck with either digging up all your printed medical documents at home (that you hopefully stored and filed), make copies and carry files appointment to appointment, or you must pay your previous physician’s office to print copies of your medical records, many times paying per printed page. Then, the next physician’s office must take your papers and somehow manage putting that information into their electronic health records (EHR) system. In general, the process is extremely cumbersome on the patient, which leads to patient frustration and lack of participation, and ultimately less information for a physician to make sound medical decisions.

Why can’t providers easily share data between each other? Why is it so difficult to share information in an age of EHRs and engaging patient portals? Shouldn’t the healthcare industry have figured this out by now? With other industries including banking and retail sharing information seamlessly, it’s hard to understand why healthcare is so far behind. Let’s break down the history behind EHRs, digital health and health information technology (HIT) below and discover some solutions.  

The Birth of HIT: Electronic Health Records (EHR)

Before the dawn of electronic health records (EHR), the healthcare industry relied solely on paper records for all documenting. The patient’s personal records were stored in their own personal file at the medical facility and retrieved by hand when needed. During the paper record days, one physician’s office would simply fax over the appropriate medical records to be used at the next office. In the digital age, faxing paper copies is simply inefficient and costs time, money and resources. Now, most health records are stored electronically on EHR systems that are either hosted on premise or in the cloud.

While EHRs have been around for decades, the industry truly took off when The Health Information Technology for Economic and Clinical Health Act (HITECH Act) was signed into law in 2009 as a part of the American Recover and Reinvestment Act of 2009 (ARRA) economic stimulus package. The bill’s goal was to stimulate the adoption of EHRs and support technology in the United States. As everyone in the healthcare or HIT industry knows, this legislation eventually led to the “Meaningful Use” regulations that incentivized EHR adoption and standards, and punished non-compliant healthcare providers with reductions in Medicare reimbursements or fines. These regulations were the catalyst for rapid adoption of EHR systems throughout the healthcare industry but also created a host of issues around interoperability and data sharing.

Interoperability: Why Don’t EHR’s “Talk” to Each Other?

At the core of the medical data exchange issue is interoperability between EHRs, and how a majority of the systems cannot and will not talk to each other. The reasons for why this happened are vast and complicated, but some of the main reasons include:

  • The HITECH Act did not include interoperability through health information exchanges (HIE) until stage 2 of the Meaningful Use requirements. This means that EHRs were programmed, developed and adopted throughout the nation without information exchange in mind at the very beginning.
  • EHR software companies compete with each other in the open marketplace and it is actually against their best interest to talk to each other. There are hundreds of EHR platforms all competing against another. The programming, interface and functionality for each vendor is their business’ “secret sauce.” Why would they want to give up their value-adds publically for others to copy or duplicate? Also, vendors can keep clients they would normally lose by making it difficult to move data to another vendor’s system. While many companies have pledged themselves committed to achieving interoperability and the Office of the National Coordinator for Health IT (ONC) providing a roadmap for EHR providers to follow, only time will tell if the market moves in the interoperable direction.
  • EHRs are not one-size-fits-all programs. Larger health systems will often have multiple EHRs to fulfill their specialized medical services. For example, one EHR may be used for the hospital, one for clinics, one for outpatient services, etc. This make scenarios even more dangerous for patients when test results can’t follow them across care settings at the same health system.
  • Health data is special and uniquely difficult. Unlike banking and retail data, health data is on its own playing field thanks to laws and regulations surrounding health information privacy including HIPAA.

These problems and more have led to a healthcare system where health data cannot easily be carried throughout the patient’s healthcare journey. Analyzing why EHRs don’t talk to each other could be an entire blog post on its own, but thankfully there are a couple of solutions currently being explored in the marketplace. 

Health Information Exchanges (HIE)

Health information exchanges (HIE) are one encouraging solution to the interoperability epidemic hitting the healthcare industry.

According to, health information exchanges (HIE) allow doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically. HIE’s can greatly improve speed, quality, safety and cost of patient care during medical data transfer. Currently, there are three distinct types of HIEs in the marketplace now:

  • Directed Exchange- ability to send and receive secure information electronically between care providers to support coordinated care
  • Query-Based Exchange- ability for providers to find and/or request information on a patient from other providers, often used for unplanned care
  • Consumer Mediated Exchange- ability for patients to aggregate and control the use of their health information among providers

HIE’s were mainly set up thanks to the HITECH Act, where the ONC awarded funds in 2010 to 56 states, territories and qualified State Designated Entities as part of the State Health Information Exchange Cooperative Agreement Program. States and state-designated HIE entities received nearly $548 million through this program, which funded states' efforts to rapidly build capacity for exchanging health information across the healthcare system both within and across states. This allowed all states to have some sort of HIE network created but vary greatly in their size, complexity and ability.

The ONC also provided funding for the Nationwide Health Information network (NwHIN) which consists of a set of standards, services and policies that enable the secure exchange of health information over the Internet. The system is not a physical infrastructure nor is it a network of patient records, rather its policies encourage the HIT community to develop interoperable HIE’s across the nation.

Benefits of HIEs

HIE’s provide many benefits to all parties involved in a healthcare exchange, including:

  • Improve patient safety by reducing medication and medical errors
  • Increase efficiency by eliminating unnecessary paperwork and handling
  • Provide caregivers with clinical decision support tools for more effective care and treatment
  • Eliminate redundant or unnecessary testing
  • Improve public health reporting and monitoring
  • Engage healthcare consumers regarding their own personal health information
  • Reduce health related costs

A recent study actually found widespread use of HIE’s could save an estimated $63 million annually to Medicare in outpatient therapeutic procedure costs.  

Transitioning from Public to Private HIEs

While the initial launch of HIE’s was rapid, it’s no secret that HIEs have gone through a sort of evolution since their boom in the early 2000’s. While enormous benefits of HIEs are known across the industry, low participation, decline in funding, lack of HIE integration into provider workflow and unsustainable business models have led to significant decline in public HIE’s over the years even with federal funding to keep them functioning. While some worry the failure of public HIE’s puts interoperability in jeopardy, others are noticing and embracing the market’s shift from public, community-based HIE’s to private models. Take a look at these startling statistics:

  • Private HIEs continue to outpace public HIEs. There were 277 sustainable private HIEs in 2015 compared to 152 in 2014. In contrast, 83 percent of the nation's 165 public HIEs are failing despite some funding to shore them up. 
  • 98 percent of healthcare organization decision makers believe that private HIEs are the preferred choice to achieve accountable care organization (ACO) deliverables. Only 2 percent of ACO managers find operational public HIEs capable of meeting their data requirements.
  • Many public HIEs have not yet figured out how to fund themselves now that the $548 million in HITECH money that supported their start-ups has run out.
  • The commercial payers, who can benefit the most from HIEs but haven't participated much yet, are investing in private HIEs and "snubbing the bureaucracies, fees and complex architecture of government sponsored HIE," which is compounding the public HIEs' sustainability problem.

In conclusion, HIE’s have a unique opportunity to solve one of the most challenging issues the health IT industry is facing if the market takes advantage of them. The journey of HIE’s from public to private raises many questions about the role of government in regulating them and if private HIE’s will ultimately become larger silos; however, the shift is clear and unstoppable.

Interested in participating or building your own HIE? The Health Information and Management Systems Society (HIMSS) provides a number of toolkits for providers looking into participating in HIEs.

What about you? What do you think the solution is for successful interoperability and data transfer between healthcare organizations and EHRs? Are HIE’s the solution or are they a failed experiment?

Tell us your thoughts below in the comments!