The Evolving Landscape of Health Information Exchange

Noam H. Arzt, Ph.D.In the past several years we have seen a real shift in leadership over Health Information Exchange (HIE) in the US. The phase out of the ONC State HIE Cooperative Agreement Program in 2014 marked a real turning point in HIE planning and implementation as ONCs leadership has waned and other more market-driven forces have ascended. Some activities have continued with funding from CMS under the Medicaid Electronic Health Record Incentive Program Health Information Technology (HIT) 90 percent Federal Financial Participation (FFP) program, and to a lesser degree under the Medicaid Management Information System FFP program. State-level HIEs have continued to flourish in some states (including Delaware, New York, Michigan, and others) while they have floundered in others.

ONC leadership in standards development related to interoperability has also shifted, from a convening role (efforts like the Standards & Interoperability Framework initiative which have terminated) to more of a coordination and documentation one (efforts like the annual Interoperability Standards Advisories). Active ONC projects are largely guided by (and largely limited by) the specific statutory requirements of the 21st Century Cures Act which includes mandates for initiatives related to a trusted exchange framework and common agreement (TEFCA, about which I have also written), patient matching, and others. But the landmark Shared Nationwide Interoperability Roadmap (October 2015) gets only passing mention and does not seem like the guiding vision or plan for anyone.

Standards development continues to be focused largely within Health Level Seven (HL7) and to a lesser degree within the Integrating the Healthcare Enterprise (IHE) initiative. Activity related to the Direct protocol for secure e-mail “push” communications takes place mostly in DirectTrust and The National Association for Trusted Exchange (NATE) and is focused largely on developing a shared trust community for Direct participants. Much of the action has shifted to HL7’s Fast Healthcare Interoperability Resources (FHIR). SMART Health IT represents one project promoting a constrained version of FHIR to promote interoperability, and the Argonaut Project is a private sector initiative trying to leverage these advancements.

But the real action has shifted to the private sector. Most of the major EHR vendors continue to develop health information exchange capabilities focused primarily on users of their own software, but they are certainly capable of providing interoperability with sites using other products (usually for an additional fee). As consolidation begins to take hold, especially in hospital settings, these single-vendor solutions will encompass a larger and larger proportion of overall transactions. As health systems acquire more hospitals, clinics, and ambulatory practices, this vertical integration serves to concentrate interoperability transactions in internal enterprise/organizational HIEs as well.

A number of important consortia have emerged as key players. The Commonwell Health Alliance, a consortium of leading EHR system vendors, is committed to facilitating anytime, anywhere access to patient records among its participants through the implementation of common standards and protocols. Commonwell’s architecture leverages a central coordinating hub which acts as a broker for participating organizations in performing queries of patient data and returns C-CDA documents in response to a query.

Meanwhile, the Sequoia Project, a non-profit, non-government entity formerly known as HealtheWay that now manages the eHealth Exchange (EHE, formerly the Nationwide Health Information Network, or NwHIN, Exchange), launched a new collaboration called Carequality which facilitates point-to-point queries by providing a look-up service for participating sites. Unlike Commonwell the response to a query is not restricted to any particular data format. In December 2016 Commonwell and Carequality announced an interoperability collaboration across the two projects.

A strikingly large number of clinical sites in the US use software that is compatible with these two initiatives, though actual implementation at most sites is still quite a long way off. Finally, the Strategic Health Information Exchange Collaborative (SHIEC) is a national association for health information organizations and its Patient Centered Data Home project which is also implementing its version of “anytime, anywhere” access to patient records for its participating organizations.

The original vision for nationwide health information exchange was a “network of networks” model where local HIEs would interact HIE-to-HIE to form a virtual national network. But notice that many of the new initiatives are essentially solving a different problem: they are enabling point-to-point connections across a wider geography and set of clinical sites. This seems more like a large, single national network rather than leverage of more distributed organizations or implementations. Only time will tell if these private sector initiatives will collaborate, converge or compete. And only time will tell of the limitations of ONC’s ability to influence and provide leadership will creates gaps or provide new opportunities for innovation.