Just how difficult is it to implement health information exchange (HIE) for public reporting? Research published online Jan. 3 by the Journal of the American Medical Informatics Association utilized systems dynamic modeling to investigate the project’s complexity in New York and determined several implications that may be helpful to others.

“HIE for public health reporting is a powerful strategy for shaping both short- and long-term policies to promote the health of populations,” wrote lead author Jacqueline Merrill, DNSc, MPH, RN, an associate professor of clinical nursing at Columbia University in New York City. “HIE for public health initiatives are underway in all 50 states, but there have been few evaluation studies that can inform these complex technical implementations.”

In 2004, New York passed legislation to develop the state’s health IT infrastructure and in 2007, three regional health information organizations received funding to demonstrate the feasibility of HIE for public reporting. The public-private partnership resulted in the development of a web-accessible universal public health node to provide these services and feasibility has been demonstrated in “test” environments.

To examine the factors affecting the public reporting of clinical measures to state public health departments using HIE, researchers collected qualitative data from six public health experts familiar with the HIE landscape of New York. To account for the complexity of HIE, researchers assessed the results using systems modeling techniques, “a computer aided approach that can be applied to evaluation and policy analysis to augment our understanding of complex social, managerial, economic or ecological systems.”

Based on face-to-face sessions with interviewees, researchers developed several diagrams mapping the relationships among internal and external factors affecting HIE activity and HIE policy in New York. These diagrams showed, for instance, how a disruption in federal funding caused development of the universal public health node to stall.

Researchers made several observations based on their results, including:

• The availability of expertise to implement HIE should not be assumed, especially in an era of public health department budget cuts;
• The implementation process will reveal undiscovered work to be done and budgets should be planned accordingly;
• Contingency plans should be drawn for every stage of implementation to avoid delays that can undermine stakeholder trust and confidence;
• Leadership should remain constant throughout the implementation process to avoid communication lags, and policymakers should consider process to ensure consistency; and
• Time delays should be expected during any large-scale technology implementation and legislators should approach HIE implementation with flexibility.

Researchers concluded that strong collaboration and careful planning can reduce the risk of encountering challenges through the HIE implementation process. “The model illustrates how exogenous shocks common to any HIE implementation—for example, leadership change, funding disruptions and political environment—interact with endogenous processes. Analyses of leverage points in this model suggest several issues that may have generalizable implications for similar HIE projects.”