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Are HIEs a Dead Horse?

Do local Health Information Exchange (HIE) participants have the right economic motivations to make them work?  

A report released this week raises strong doubts. The study — Creating Sustainable Local Health Information Exchanges: Can Barriers to Stakeholder Participation be Overcome? — was  funded by the U.S. Agency for Healthcare Research and Quality (AHRQ) and conducted by the Center for Studying Health System Change (CSHSC). The term HIE is often used interchangeably with RHIO (Regional Health Information Exchange).

What’s different about this study? The CSHSC report goes a step further than other recent reports documenting minimal progress by most HIEs and questioning whether HIEs have a business model. Through interviews with HIE participants — hospitals, physicians, health plans, employers — it brings evidence from the horse’s mouth suggesting

  1. the rationale TO share data is WEAK, and
  2. the rationale NOT TO share data and to preserve the status quo is STRONG. 

The next question becomes “Is it time to get off the dead horse?” Does it make sense to put more time and energy into a flawed model model and further delay national efforts to create interoperable electronic health records?  Are HIEs doing more damage than good?

Here are some of the key conclusions:

In the study communities, provider organizations still face substantial disincentives and few incentives to share data with unaffiliated organizations…

…a core feature of the health care marketplace has remained unchanged since the failed CHIN efforts: “Institutions and provider practices treat health data as a business asset over which these organizations can exert property rights.”….

In such an environment of competing models, it is unlikely that development of local HIEs will be sufficiently widespread to support a national health information network. (emphasis added)

Having spent the first 15 years of my career in the trenches of local health delivery systems, this report fulfills my worst fears about the type of bartering and decision making that has been occurring in HIEs and within participant organizations. The authors reached these conclusions by interviewing multiple parties — hospitals, health plans, physicians, employers — in four different communities.  Here are some of the “fox in the hen house” motivations that are revealed:

Hospitals’ greatest concern in weighing the costs and benefits of participation in…was losing competitive advantage by relinquishing control of “their” data. They viewed clinical data as a key strategic asset, tying physicians and patients to their organization….Hospitals were concerned that direct competitors or other parties might use data in ways that could harm the organization’s business interests, for example, by using the data for marketing purposes to redirect patients to other providers. Of particular concern was use of data for hospital performance measurement.

The hospital systems and other founding HIE members negotiated agreements protecting providers’ competitive interests by limiting data use. In particular, data could not be used to compare provider organizations or individual physicians for any purpose, including quality reporting and P4P, without approval. Furthermore, these HIEs’ governance structures gave founding members primary control over such changes.

…health plans started developing proprietary IT networks to support health plan administrative functions, such as eligibility verification. This limited health plan motivation to participate in data exchange activities.

…competition among hospitals, physicians and health plans and the “oppositional interests of providers and payers,” as described by HIE staff, were seen as barriers to using HIEs for quality initiatives.

Most statewide and national health plans in the four communities noted they were planning to participate in only select HIEs that the companies believed fit well with their corporate strategies.

The study findings suggest that the substantial barriers to community-wide clinical data exchange identified in the wake of the failure of the CHINs of the 1990s continue to exist today. Many HIEs, including those in this study, have substantial stakeholder participation at their outset. However, when participation is defined more narrowly as providing data, using data or providing sustained funding for data exchange, the degree of stakeholder participation drops off rapidly, as the study findings demonstrate.

Is the horse dead? Is it time to get off and try another horse? You can decide for yourself.  At the very least, we need to face up to the reality that the current economics of HIEs/RHIOs are unworkable.

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