Is bigger better? A number of health information exchanges (HIEs) across the U.S. are finding that scaling up is good for both business and healthcare.

HIEs are growing, with some opting to merge, others linking disparate systems and one jumpstarting its operation with a hefty investment from two major insurance companies. The best path to improved healthcare delivery and financial viability remains to be proven. 

Mergers & Data Sharing

Some HIEs with similar missions are opting to merge. The year of 2014 saw several such mergers, including one in New York that joined two regional HIEs into a single, unified qualified entity called HealthlinkNY. Also, some HIEs are sharing clinical data, including two Missouri HIEs—the Lewis and Clark Information Exchange and the Tiger Institute Health Alliance—which decided to link their systems to improve accuracy of patient matches.

The most high-profile merger took place in July when Michigan Health Connect and Great Lakes HIE joined forces to form Great Lakes Health Connect. The combined HIE serves more than 5 million patients.

The organizations had been eyeing a merger for some time, according to Doug Dietzman, executive director at Great Lakes Health Connect. In 2013, the organizations agreed on a Memorandum of Understanding to explore the possibility. “As we had conversations early on, we saw that our visions were similar, our missions were similar and we felt we could accomplish them better together than separately.”

The merger required a technology review in both organizations to decide which one would be the go-forward platform. In the meantime, the HIE is using a hybrid model, “mostly to bring data to the middle,” Dietzman says. The “complex” conversion effort entails coordinating receivers of data on the outbound side and coordinating interfaces coming in. “We don’t leave provider offices in the dark.”

The HIE, which is opt-out, includes medical information, lab results, transcription, Consolidated-Clinical Document Architecture, ADT alert capability and it’s in the early stages of exchanging images, Dietzman says.

For Great Lakes Health Connect, having a single-network HIE, as opposed to linking multiple disparate EMRs, is more effective. “Interoperability is a conversation, a process, and the more you have folks operating on the same exchange platform, the more efficient you are and better at meeting patient needs,” says Dietzman.

Great Lakes Health Connect is looking into developing analytics capabilities, but Dietzman notes that fostering trust must come before taking that step. “We are taking a pragmatic approach. We need permission from the organizations when we are moving in that space, and in a context that doesn’t spoil and ruin the trust we’ve developed,” he says.

Linking Systems

State HIEs like Georgia’s Health Information Network (GaHIN) and South Carolina’s HIE (SCHIEx), however, are following a federated approach, linking their systems but keeping data housed within individual organizations.

GaHIN serves with the Georgia Department of Community Health and the Georgia Health IT Extension Center in a public-private collaborative to develop the state HIE. The organizations enable the exchange through governance, project management, policy development, business and financial planning, technical infrastructure development, marketing and stakeholder engagement.

GaHIN went live early in 2014 with Healtheway, and shortly thereafter began seeking out partners in bordering states, according to its executive director, Denise Hines, PhD. As many patients straddle the Georgia and South Carolina line, GaHIN and SCHIEx agreed to link the two systems, which went live on Sept. 24, 2014. This fosters exchange of GaHIN’s 16 million medical records and South Carolina’s 680,000 records.

The HIEs’ federated hybrid model, which utilizes a master patient index and record locator but does not store clinical data, “helps the originating organization maintain more control over the information,” Hines says. “It helps with allaying fears of what will happen with data.”

In the end, the ultimate goal is patient care. “Part of the value is that the more providers connected, the more information can move to downstream providers. But the ultimate goal is to be able to provide care for the patients,” she says.

A New Solution?

Cal INDEX, a newly incorporated independent exchange in California, is moving forward with a novel approach to HIEs. Blue Shield of California and Anthem Blue Cross are funneling $80 million over the next three years to build out the exchange, which will initially provide access to approximately 9 million health information records.

Both insurers required HIE capabilities to support their partners in risk-sharing agreements and separately came to the conclusion they would build their own private exchange.  When they realized that both of them independently were about to spend significant money to create identical services, they had an “aha” moment, according to Dave Watson, CEO of Cal INDEX. They asked themselves, “’We compete in the marketplace, but do we have to compete around a utility like HIE?’”

The “founding members” agreed to fund an independent exchange, set to go live by the end of the year. To prepare, the organization hired staff, prepared commercial agreements and privacy policies and delivered the final technology platform, he says. At its launch, Cal INDEX included the records of 20 percent of the state’s population. “That’s a good start.”

Watson uses a three-story house metaphor to describe where Cal INDEX is heading. The foundation of the HIE is where data are acquired, curated and managed. The first floor consists of the payers and providers who contribute data to the patient record and who pay for access. The second floor consists of patients—as the HIE intends to allow Californians free access to their longitudinal medical records on the system (the system is opt-out).

Once this network of payers, providers and patients is built, the HIE will venture into yet-to-be-defined products and services, he says. For patients, this may be the ability to upload data from wearable fitness devices and other sources. For payers and providers, it may be analytics. “There are so many possibilities, it’s endless.”

Sustainability

To achieve sustainability, the expanded HIEs are hoping to drive as much value as possible to the user.

GaHIN currently is maintaining its operations from federal funds, but once that ends it plans to seek out grants, private donations and sell value-added services to its users, says Hines. Members are interested in alerts, discrete results delivery for lab information, medication fill information (to know if patients got their medications billed) and analytics, among other functions. “We’re actively working on that now.”

“The business case for HIEs is stronger now than it ever was,” says Watson. After 2017, Cal INDEX is expected to be self-sustaining. Providing usable access to a mass of data for payers and providers “is at the heart of our value proposition.”

Watson feels like while many HIEs fail, Cal INDEX really has a shot at success. With the rise of risk-sharing models, and providers beginning to recover from their EMR investments, and the generation of significant computable clinical data, the time has come..

“Given these circumstances, we should be able to achieve a high-value, revenue-stable model. That’s why I took the job,” he says.