It’s Time For A New HIE Model

Over the decade or so I’ve been writing about HIEs, critics have predicted their death countless times – and with good reason. Though their supporters have never backed down, it’s increasingly clear that the model has many flaws, some of them quite possibly fatal.

One is the lack of a sustainable business model. Countless publicly-funded HIEs, jumpstarted by state or federal grants, have stumbled badly and closed their doors when the funding dried up. As it turns out, it’s quite difficult to get hospitals to pay for such services. Whether this is due to fears of sharing data with the competition or a simple reluctance to pay for something new, hospitals haven’t moved much on this issue.

Another reason HIEs aren’t likely to stay alive is that none can offer true interoperability, which diminishes the benefits they offer. Admittedly, some groups won’t concede this issue. For example, I was intrigued to see that DirectTrust, a collaborative embracing 145 health IT and provider organizations, is working to provide interoperability via Direct message protocols. But Direct messaging and true bilateral health information exchange are two different things. (I know, I’m a spoilsport.)

Yet another reason why HIEs have continued to struggle is due to variations in state privacy rules, which add another layer of complexity to managing HIEs. Simply complying with HIPAA can be challenging; adding state requirements to the mix can be a big headache. State laws vary as to when providers can disclose PHI, to whom it can be disclosed and for what purpose, and building an HIE that meets these requirements is a big deal.

Still, given that MACRA demands the industry achieve “widespread interoperability” by 2018, we have to have something in place that might work. One model, proposed by Dr. Donald Voltz, is to turn to a middleware solution. This approach, Voltz notes, has worked in industries like banking and retail, which have solved their data interoperability problems (at least to a greater degree than healthcare).

Voltz isn’t proposing that healthcare organizations rely on building middleware that connects directly to their proprietary EMR, but rather, that they build an independent solution. The idea isn’t incredibly popular yet — just 16% of hospital systems reported that they were considering middleware, according to Black Book – but the idea is gaining popularity, Voltz suggests. And given that hospitals face continued challenges in integrating new inputs, like mobile app and medical device data, next-generation middleware may be a good solution.

Other possible HIE alternatives include health record banks and clearinghouses. These have the advantage of being centralized, connected to yet independent of providers and relatively flexible. There are some substantial obstacles to substituting either for an HIE, such as getting consumers to consistently upload their records to the record banks. Still, it’s likely that neither would be as costly nor as resource-intensive as building EMR-specific interoperability.

That being said, none of these approaches are a pushbutton solution to data exchange problems. To foster health data sharing will take significant time and effort, and the transition to implementing any of these models won’t be easy. But if the existing HIE model is collapsing (and I contend this is the case) hospitals will need to do something. If you think the models I’ve listed don’t work, what do you suggest?

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.


  • In my mind, the exchange required for interoperability is not exchange with the EHR record (which is often wrong), but exchange with a single patient record. If EHRs posted data to the patient single “record” and this record had a defined format, interoperability, without the multitude of integrations in the middleware solution, would be accomplished. With patient-controlled access rights, many of the HIPAA, and other regs, would be met, and analytics across multiple patients would make support across the entire patient care continuum possible.
    The model for such a single patient record is that of a “data custodian”, an entity responsible to stakeholders in patient care; the patient, the providers, payers, government, research, etc. We should be moving to build the infrastructure that implements the data custodian model to solve healthcare’s problems.

  • “It’s Time” – yes it is.

    The HIE model misses the point and in current form, will never succeed.

    So what is the point? Well it definitely is not technology.

    There is a simple logic lost in the years of discussion, (and countless billions of investment and incentive dollars) relative to data sharing in healthcare. The logic is one of supply and demand. In the case of health data there is a natural market. The market consists of “suppliers” those individuals, devices, organizations and entities that create health data and “consumers”, those organizations and entities that consume data in the creation of products (medical devices, mobile apps, pharmaceutical and bio therapeutics, etc.) and services (the delivery of care, condition management, analytics, etc). What does not exist is a marketplace that connects suppliers and consumers. (Yes health data is complicated by “ownership” – whose data is it? But if the “patient” is given a simple means of authorizing who, when, where and how their data is used, a fully functioning health data marketplace is quite possible.)

    A health data marketplace provides “utility” functions – connectivity, interoperability and consumer consent management. The marketplace moves data it does not “utilize” data.

    This past February some 40,000+ people gathered in Las Vegas to consider all of the amazing possibilities relative to the use of data. As I toured the exhibit floor and marveled at all the innovations, I’d frequently stop at major exhibits of the power players – Intel, Epic, IBM, Optum, Verizon, Cerner and startups alike and ask the question – “isn’t the value of your solution regulated by your access to data?”. The answer was universal, “yes, but….we can connect to any data source, just tell us what sources you need”.

    Therein lies the fallacy of the data-based health industry revolution – “I don’t know what data sources I need to connect – because I do not control consumer/patient behavior.” If a patient opts to go to a retail clinic because it is convenient; if an employer opts to establish worksite health clinics, if an entrepreneur decides to create a diabetes management platform that is offered nationally, has a monthly subscription fee but is appealing to consumers with diabetes – I can’t control any of that – but if I’m a primary care physician, a hospital system that just admitted someone to the ED – yes I would like to have access to the relevant data that can help me provide the safest, most cost effective and optimal care for my patient.

    Like so many industries that have encountered “organizational” based transformation, (think financial services – credit cards/ATMs; travel – Sabre; transportation – Uber, retail – Amazon, ebay) healthcare is primed.

    The impact of a “health data marketplace”? A sustainable business model. Pull vs. push market behavior – organizations connect to a marketplace because they want to – they get value – the opportunity to improve outcomes, develop new revenue streams, manage costs, grow brand loyalty.

    We are deploying such a marketplace (as a test) in Austin, TX. We’ve been reviewing our plans with organizations like Dell, Optum, IBM, Seton/Ascension Health, St David’s/HCA, the major physician practices, the dominant lab provider, the Dell Medical School at UT Austin, the American Heart Association, CPRIT and CDISK among others.

    So Anne, yes there are other models. And if history is any indicator, innovations driven by industry “organization” have come a long way. (Sabre – envisioned in 1953; IPO in 2000; Visa – envisioned 1958 – global in 1974; Uber – envisioned in 2009 – global in 2012.)

    It’s time for healthcare.

    Brian Baum
    CEO vitaTrackr

  • I try to see this from a very simple viewpoint; the patient. You are in an ER, most likely due to an ongoing condition, or even if something new, it is critical that the ER has access to your medical data. Plus, if a doctor sent you, the ER must have his detailed instructions for your care. In an example of the first, a patient comes in with an orthopedic situation that is a new episode of an existing condition, where another hospital not that far away has records your ER needs – but can’t get for days awaiting medical records to fax it over. In a second, your doctor sends you in for emergency treatment with very specific instructions, only the instructions – due to come by phone or fax, never arrive, because his office is part of a different organization that does not have ready access to the ER’s (or hospital’s) EHR, and some office person or the doctor forgets to send the fax or make the call.

    I understand the technical issues, plus the reasons an organization wants to avoid sharing data and therefore possibly risk loss of revenue. Result is that the will to overcome the difficulties won’t be there unless someone provides enough of an incentive to change the behavior of all participants.

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