Making Health Information Exchange Work: HIOs Currently Not Ready to Support the Information Needs of a Reformed Healthcare System—But Small Changes Offer Big Outcomes

By Kathy Callan, MA, RHIA; Jan Fuller, RHIA, CPHIMSS, FAHIMA; Lou Galterio, MBA, FHIMSS, CHIME, CP; Beth Just, MBA, RHIA, FAHIMA; Kimberly Reich, MBA, MJ, PBCI, RHIA, CPHQ, FAHIMA; Christine Steigerwald, MBA, RHIA; Mary Lou Turner-Combs, RHIA; Sheldon H. Wolf; Julie Dooling, RHIA, CHDA; Annessa Kirby; and Harry Rhodes, MBA, RHIA, CHPS, CDIP, CPHIMS, FAHIMA

Editor’s note: This article is part two of a two-part series analyzing the current state of health information exchange organizations and their operational models.

The question facing the healthcare industry is “will health information exchange organizations (HIOs) be ready to support the information needs of the new value-based, patient-centric, and outcomes-measured health system?” The first installment of this article published in the October 2014 Journal of AHIMA reviewed the variability of health information exchange (HIE) models and definitions being deployed. HIE and the formal HIOs that facilitate exchange are increasingly influenced by the growing consensus that an eventual consolidation of internal and external exchange models is certain. This consolidation is being driven by the market need to achieve true interoperability and information governance in healthcare.

Public Health Reporting Using HIE

Entities can use health information exchange to send data to public health entities, but typically do so in different ways depending on the HIE model being employed.

EHR-Based Exchange

Reporting in an EHR-based exchange to public health may be completed in two ways—manually, or by a direct electronic connection. This exchange can be completed manually by mail or fax. For the exchange to occur electronically, a direct connection must be built between the EHR-based exchange and the public health department, possibly using a formal exchange protocol, like Direct exchange protocol, for secure e-mail transmission.

Any change in reportable conditions or syndromic surveillance data must be made in each system that is connected directly between the EHR-based exchange and the public health unit. This results in coordination between the provider, the provider’s vendor, the public health department, and their vendor. Consequently, each change requires time and human and monetary resources to change each and every connection.

HIO Model Exchange

Normally all transactions are handled electronically through an HIO model exchange. Each provider builds a link to the HIO and routes all their data to the HIO, which houses it in a centralized, federated, or hybrid database model. The HIO can scrub the incoming data and identify and normalize data that is required to be sent to the public health department.

Any data requirement change by the public health unit can be coordinated between the public health unit and the HIO. A system change can be made in the HIO and new data requirements can begin to flow to the public health department for all providers connected to the HIO.

Utilizing an HIO model exchange can also provide other benefits such as quality reporting and giving providers access to information held in state-wide repositories, such as advance directives.

HIE Currently Available in Three Stages

Health information exchange can be both a noun and a verb. Typically, when HIE is being referred to as a noun it is in reference to HIOs—entities who facilitate the digital exchange of health data. As a verb, HIE is the actual exchange of health information data between two or more entities.

Some organizations view the concept of health information exchange as a “verb” instead of a “noun.” From this perspective, HIE is not seen as an entity. Instead it is seen as a data sharing activity. Health information is captured, coordinated, updated, and shared. In this healthcare ecosystem, clinical information is not kept or stored in one place. HIOs typically update and move data between different healthcare systems, but the data are not kept or stored in one place. In some healthcare organizations they simply use HIE to exchange information either internally or with outside organizations—and do so without formally connecting to an official HIO.

In most hospital settings, the typical exchange activity can fall into both HIO and HIE definitions. If one looks at the characteristics of an IT department charged with extending HIE to the rest of the hospital at large, that department, in general, has the same traits as a “non-profit” subscription HIO in the outside commercial world selling data links to individual purchasers.

However, in the ambulatory market, with those electronic health record (EHR) vendors selling the HIE functionality to providers and clinics, there is a much closer alignment to the “for-profit” transaction HIO model of the commercial space.

HIE experts are starting to see a three-stage development in this commercial health information exchange market:

  1. “Record and Playback” stage
  2. “Local Limited HIE” stage
  3. “Full Station” stage

Entities on this journey often begin in the “Record and Playback” stage. In this stage, providers purchase EHR systems that simply record their records and read them back when desired. Seeking to advance into the information sharing stage, providers often pass into the second “Local Limited HIE” stage, with limited HIE functionality that often locks providers in local information sharing scenarios within the same office or building, or in a tight local network, with constrained communication of records and patient data with other providers. Finally, in the third “Full Station” stage, providers without an HIE are like consumers with a radio but without a radio station network ready to broadcast information to the radio or EHR. There is a need to “tune in” to the right station, or the larger “HIE,” in order to exchange records with the proper provider. Many providers view their purchased EHR software as non-functional without this HIE capability and may view the EHR product as a deficient purchase if it does not perform HIE as they feel it should.

For many providers, access to a HIE is considered a standard feature that should be included in the purchase price of an EHR, and not be merely an option. The question has become “What is the cost to tune in to HIE?” Is it a public service, a private pay-as-you-go subscription type service, a free-yet-private service saturated by commercial messages, or some hybrid appropriate to specific markets served? Only time will tell what shape those HIE airwaves take.

Healthcare Reform Driving HIE Integration in EHRs

The concept of looking at data exchange in a “for-profit” HIO is different than looking at data exchange in a “non-profit” HIO. The non-profits usually tend to operate best in a subscription model.

HIE will need a variety of models to be able to scale up sharing among physicians, hospitals, and patients and across care settings. Farzad Mostashari, the former national health IT coordinator for the Department of Health and Human Services (HHS), says health information exchange will not become a reality as a single vision or system but instead include many models and business plans. The evolving HIE vision must be built around standards, directories, participation agreements, governance models, and a clear understanding of different ways that information can be shared and understood.1

Interest in health information exchange has risen dramatically in response to initiatives such as the “meaningful use” EHR Incentive Program, accountable care organizations (ACOs), and the restructuring of provider payment models. A 2011 CapSite survey of 340 hospitals found that 74 percent plan to purchase health information exchange solutions, double from when CapSite surveyed hospitals in 2009.2 While the market grew in excess of 40 percent in 2011, only a small portion of growth was due to grant-funded state-level HIEs, according to the 2012 HIE Report by Chilmark Research.3

HIE vendors are targeting the private “enterprise” market. The number of private EHR-based health information exchanges rose from 52 to 161 from 2010 to 2011, according to a KLAS report. A survey of hospital CIOs in 2012 found that nearly 60 percent were currently involved in a regional or system-to-system HIE effort, though roughly 21 percent said they were “skeptical” of HIE sustainability. A HIMSS Analytics survey in 2013 showed that 73 percent of all hospitals are involved with an HIO, and over 50 percent of the HIOs offer state-wide exchange.4

Whether private or public, health information exchange must add value, be sustainable, and integrate into a healthcare provider’s workflow to be successful. Private EHR-based exchanges provide local solutions that are more responsive to a smaller number of providers, more sustainable, and have better integration into provider workflow. Data reliability is also improved with the likelihood that all stakeholders will participate and share data.

As EHR standards are adopted, interoperability will improve. There is a greater interest by EHR vendors in developing common standards and policies for HIE as evidenced by the six major EHR vendors forming their own consortium, The CommonWell Health Alliance, in 2013 with the goal of promoting and certifying a national infrastructure with common standards and policies for health information exchange.

While private health information exchange has these advantages, public health information is better at creating needed services, such as a provider directory, and at establishing connectivity for public health and quality reporting. Public health information exchange models are often dedicated to the public good. Therefore, a “hybrid” HIO with a public-private partnership may achieve the best of both worlds.

Public Data Exchange Working as an HIE Convener

HIE will continue to evolve and mature, and the healthcare industry will likely see both private and public models continue. Public health data exchanges have some unique considerations, and possible HIO participants should evaluate several points prior to signing up to participate in an HIO.

There are many advantages to both the healthcare industry and the healthcare consumer to using a public HIO to exchange data:

  1. Public HIOs have the neutrality necessary to work with private exchanges to extend their functionality to providers outside of the community in which the private HIO was developed.
  2. Public HIOs (particularly state-wide entities) are uniquely positioned to develop both intrastate and interstate exchange as they can use their statutory and regulatory rulemaking authority for sharing and protecting individual patient data and addressing challenging issues regarding patient consent, according to the eHealth Initiative’s 2013 white paper “Building Effective Data Governance Models, Policies and Agreements in a HITECH World.”5
  3. Public HIOs are required to be transparent and as such can more clearly establish ownership of the data governance process. If one organization or one vendor alone owns this effort, other stakeholders may feel that the data governance initiative does not meet their needs, according to the eHealth Initiative white paper.
  4. Data quality, integrity, security, use, and reuse all must be addressed in the data sharing agreement. There may be greater risk of an incomplete data sharing agreement and of misuse of information in the private HIE environment. This statement assumes that the information exchange that occurs is secondary to the care transaction. Being a byproduct of the transaction, formal data sharing agreements may not exist.
  5. Overall costs to participating organizations could be less in a public HIO. When the public HIO is connected to public health registries, the participating organizations build their interface one time to connect to the HIO. As the public health entity modifies their interface requirements, the health information exchange organization participant does not need to modify their interface to the HIO (unless the addition of a new data field is required).
  6. Costs to public health departments could be reduced as they won’t need to manage interfaces with hundreds or even thousands of providers’ HIOs. Additionally, if the HIO utilizes technology with advanced record matching algorithms, the HIO can connect various public health reports (such as immunizations) for one patient, minimizing the chance of duplicate patient records within the public health registry.
  7. Quality patient matching is expensive both in technology and data management costs. Public HIOs could be viewed as a “utility,” thereby consolidating this expensive process within larger public HIOs.
  8. Population health management may be more comprehensive in a public HIO. Private organizations or vendor-based HIOs are not as likely to have a comprehensive set of patients.
  9. Public HIOs are better able to create services such as a comprehensive provider directory (through state credentialing and licensing agencies) and at establishing connectivity for public health, quality reporting, and advanced directives.
  10. Public HIOs serve a vital role in bringing data exchange to rural communities and driving adoption of the nationwide health information network (NwHIN) standards and services.

Recommendations for Building a Sustainable HIO

To ensure an HIO remains viable into the future, seven key elements are required—entities must have a vision, a governance entity, a sustainability plan, value, workflow integration, trust, and interoperability with other HIE networks both within their state and across state boundaries.

The first focus of a successful HIE is to develop a governance entity that engages the provider community—and potentially, if a public HIO, stakeholders from payers and government agencies—early in the process.

Not every individual needs to be included on the governing board, but they need to be able to have a say in the process. This can be accomplished by having domain workgroups that work on issues and make recommendations to the board for final approval. Examples of domain workgroups may include: legal and policy, finance, communications, technical, clinical, data, and business operations.

To best serve the community and identify value, it is important to include stakeholders early in the process. For example, if one of the identified values of the HIO is a process to share information between stakeholders for care coordination to meet the meaningful use program, Direct secure e-mail may be a service that can be put in first as a quick win. Additionally, by including stakeholders early on, they can work together, get to know each other, and design systems, policies, procedures, and agreements that are acceptable to all stakeholders.

This building process ultimately leads to trust amongst the stakeholders, and also helps to ensure that the HIO’s policies, procedures, and technical infrastructure is integrated into the workflow of the various participants’ hospitals or physician practices with limited interruptions, therefore maintaining continued use.

By including stakeholders initially, HIO developers can also identify exchange partners that currently do not participate within the HIO. Once these are identified, a process can be put in place to share information with partners, using such things as eHealth Exchange supported by Health-e-Way, Direct secure e-mail, which is connected through organizations such as Direct Trust, or by building direct connections between the HIO and other stakeholder systems.

Currently, few studies have been completed to determine the benefits of an HIO. Therefore, it is important for the future of HIOs that short- and long-term visions be developed and communicated to stakeholders. This will allow stakeholders to see how the HIO can help improve healthcare quality, patient safety, overall efficiency of healthcare, and public health services. By implementing this vision, stakeholders will see the value of the HIO and will participate in sustaining the entity.

HIOs can be funded in multiple ways. They can be financed like a public utility, where the payment is coming through a government agency. This could be paid for by a tax, for example an HIO fee collected from every individual insured within the state, or it could be paid from a state’s general fund budget.

Funding can also be based upon services provided—for example, transactions fees or charges for the number of Direct e-mail addresses, records stored, records inquired upon, etc. Funding could also be based upon a participant fee. For example, each provider pays a yearly subscription to the HIO, or each hospital pays a per-bed assessment. The HIO could also be funded by fees assessed to payers.

Finally, the HIO could be funded through any combination of these options or others not identified. The key in a sustainability plan is to base all services upon value and the stakeholders’ long-term vision.6,7


  1. Miliard, Mike. “HIE: Exchange rates” Healthcare IT News. December 20, 2013.
  2. CapSite. “2011 U.S. Health Information Exchange (HIE) Study.” October 2011.
  3. Chilmark Research. “At Last, It’s Here: 2012 HIE Market Report.” May 10, 2012.
  4. Pedulli, Laura. “HIMSS Analytics: Successful HIE requires paper-based strategies.” Clinical Innovation and Technology. September 24, 2013.
  5. eHealth Initiative. “Building Effective Data Governance Models, Policies and Agreements in a HITECH World.” 2012.
  6. Hagland, Mark. “Health Information Exchange: Are We At An Inflection Point?” Healthcare Informatics. August 30, 2013.
  7. Conn, Joseph. “Shortchanged exchange: Lack of incentives leaves many facilities unplugged.” Modern Healthcare. March 10, 2012.

Kathy Callan ( is director, HIM/clinical systems, information systems at Gundersen Lutheran. Jan Fuller ( is associate professor at Louisiana Tech University. Lou Galterio ( is president of SunCoast RHIO, Inc. Beth Just ( is CEO/president of Just Associates, Inc. Kimberly Reich ( is privacy and compliance officer at Lake County Physicians’ Association. Christine Steigerwald ( is senior director of HIMS operations at Banner Health. Mary Lou Turner-Combs ( is enterprise MPI project manager at the Kentucky Governor’s Office of Electronic Health Information, Cabinet for Health and Family Services. Sheldon H. Wolf ( is the North Dakota health information technology director. Julie Dooling ( is a director of HIM practice excellence at AHIMA. Annessa Kirby ( is a practice council manager at AHIMA. Harry Rhodes ( is a director of HIM practice excellence at AHIMA.

Article citation:
Callan, Kathy; Fuller, Jan C.; Galterio, Louis; Just, Beth Haenke; Reich, Kimberly A. Baldwin-Stried ; Steigerwald, Christine; Turner-Combs, Mary Lou; Wolf, Sheldon H; Dooling, Julie A; Kirby, Annessa; Rhodes, Harry B.. "Making Health Information Exchange Work: HIOs Currently Not Ready to Support the Information Needs of a Reformed Healthcare System—But Small Changes Offer Big Outcomes" Journal of AHIMA 85, no.11 (November 2014): 32-36.