In our attempt to offer the marketplace genuine value, HIEWorks aims to offer our readers a combination of information and experienced-based opinion.  It is therefore necessary for HIEWorks to occasionally stake out a position, popular or not, when it may be more convenient to sit on a fence.  HIEWorks, is genuinely concerned with issues related not only to making HIEs functional, but, more importantly, leveraging HIE services to accomplish the greater goal – improving healthcare.  So, let me get to my point very succinctly: monolithic, state-based HIEs are not the best vehicle for leveraging federal and state investment dollars intended to improve healthcare through information technology adoption and modernization. I’d like to address three specific reasons I believe this to be so. 

Accountability and responsibility:  Accountability for clinical and administrative data exchange is diluted by the introduction of numerous layers of bureaucracy, leaving no clear desk at which the buck stops. Consider healthcare reform: providers are incented and penalized (via reimbursement) based on measurements regarding the quality of care.  Several information technology initiatives are underway to support quality care improvement; critical among those are HIE initiatives.  How can providers’ reimbursement be based on quality care and outcomes when the systems designed and implemented to support improvement are governed by an organization outside the control of the health system being evaluated? 

When a state-based initiative charges for a solution, the problem is exacerbated.  In short, doing so creates the appearance that control is transitioned over to the “buyers”. But, in reality, a solution forced on a health system arms those that should be accountable and responsible with the argument that they did not choose the technology and service and therefore can’t be held responsible for its performance and errors. Making matters worse is the appeal, to some, of the potential to abdicate such important clinical information management and communications responsibility.    

Innovation: There’s no better way to douse the innovative spirit than to off-load technology assessment, selection, and implementation to government-sponsored entities without the support of the “invisible hand of self-interest”.  Time and again the drive for competitive advantage has led to rapid and beneficial innovation.  Loss of such a drive creates complacency, and stagnation. 

The perfect opportunity exists now to seize on the clinical data digital revolution.  Let us not squander this opportunity by putting crucial information technology decisions in the hands of those that are not “in the field” and empathetic with providers in desperate need of clinical information access when and where care is provided.

Regional Nature of Healthcare:  All too often state-based HIE initiatives fail to appreciate the real-world regionalization of healthcare and underestimate the communication standards that do exist and are being developed currently. While healthcare is clearly a regionally-based market, health system service areas regularly cross state lines.  As a result, there are numerous technical, operational, legal, and regulatory issues that require rigorous analysis and accommodation. In a state-based initiative, who is responsible for handling such diverse requirements that result from the need to cross state lines?  Are the needs of a community in the middle of a state that has no issue with state boundaries the same as those communities that sit along state lines with patient care crossing into many states, at times?  These are real issues of consideration that are hampered by abdicating HIE choices and implementations to the state.  In short, state boundaries are arbitrary in the context of a patient’s network of care.

Summary: If a state wishes to assist with health information exchange, great!  Provide financial incentives to health systems to acquire and implement solutions for which the health systems feel responsible and accountable – let choice serve as the basis for such responsibility and accountability. The state funding should come with the stipulation that these networks can interoperate, thus accomplishing ONC’s goal of interconnecting physicians across the state.  Health systems should be provided the opportunity to compete for physicians and patients using information technology as a competitive advantage.  If the same solution is used by all because the state selects that solution, the state is 1) enabling health systems to abdicate responsibility and accountability for critical information technology selection, implementation and adoption, 2) dissuading free market competition and thus muting innovation, 3) drawing arbitrary boundaries around care geography that have no real relationship to patient movement.