data_binary_code_2 - usedHIEs continue to tackle key challenges as vendors debate who owns the data and providers worry about patient appropriation.

By Aine Cryts

Healthcare is fragmented, inefficient, and sometimes dangerous, says John Kansky, president and CEO of the Indiana Health Information Exchange (HIE). “In each of these situations, information is a key piece of the solution.”

Launched in 2004, Indiana’s HIE is one of the country’s oldest, and it has some successes to tout. The nonprofit HIE serves more than 106 hospitals and a growing number of payers and long-term and post-acute care organizations, according to Kansky. The exchange also facilitates the sharing of data among more than 25,000 clinicians (which is larger than the number of clinicians in the state because the exchange also serves patients who live or receive care outside of Indiana).

Indiana’s HIE was formed in part by the Indianapolis-based Regenstrief Institute, an informatics and healthcare research organization that helps to improve the quality of care. Other founding partners include private hospitals, local and state health departments, and other healthcare and community organizations.

John Kansky, President and CEO, Indiana Health Information Exchange

John Kansky, President and CEO, Indiana Health Information Exchange

One of the HIE’s early challenges was getting healthcare providers onboard, according to Kansky. Now, with more than ten years of experience, the organization’s most compelling argument to providers who are not part of the exchange is that they’re “surrounded by [it],” he says. “It’s much easier now that we’ve gotten past the early adopters. Now we’re working on the laggards.”

According to Kansky, it is helpful to remind physicians that with increased information about their patients via the HIE, they can practice better medicine. The metaphor he likes to use is that of a puzzle. “Even when we assume there are missing pieces here or there, by golly, you can see what the puzzle looks like at a high level of detail,” he said. “Emergency room doctors are used to assessing and treating in the absence of information. They see patients they’ve never seen before and they may never see them again. If they [can] have access to information about their patients, wow.”

Western Massachusetts Exchange Shows Early Promise

The Pioneer Valley Information Exchange (PVIX) is a regional HIE that covers Western Massachusetts. In existence since 2013, the nonprofit exchange was initially funded by Springfield, MA-based Baystate Health and is supported today by fees from its member organizations.

Joel Vengco, vice president and CIO at Baystate Health, says PVIX has been able to “knit the community together and open the conversation across providers and organizations that haven’t necessarily been collaborative over the last decade. They’re more collaborative today because of PVIX.” Still, it’s not easy to get everyone on board. Some providers are holding out, he says, and it is largely because of distrust over sharing patient information with providers they view as their competitors.

Joel Vengco, Vice President and CIO, Baystate Health

Joel Vengco, Vice President and CIO, Baystate Health

Despite those hold outs, PVIX is beneficial for patients because information about them is being exchanged among physicians, even if those physicians aren’t connected to one another through ownership or employment, according to Vengco. “It’s valuable to have all of these organizations connected together through the exchange because it provides access to patients’ records; providers wouldn’t have digital access to their records otherwise.”

Encouraging ongoing usage of the exchange means providing tools for communication and collaboration among doctors. PVIX recently deployed secure texting for providers and plans to launch the capability to view images via the HIE as well; currently in pilot phase, this image-viewing capability is scheduled for launch this fall. Vengco says that a lot of primary care doctors are excited about the capability of viewing patients’ images. Also in the works is an algorithm to help with patient-provider matching and the ability to use the PVIX platform to deliver e-visits to patients.

HIEs Face Ongoing Hurdles

A recent article in Health Affairs1 questions the value that today’s HIEs provide. Despite incentives by the federal government—and the fact that about two-thirds of hospitals and approximately 50% of physician practices are part of exchanges—this literature review found that there is no strong evidence that HIEs are helping to improve patient care today. Even so, as acknowledged in the Health Affairs article, most HIEs are new and any research that has been done occurred within the context of relatively new exchanges where usage has been low.

HIEs continue to face three key challenges: Working with vendors; distrust and competitive pressures between provider organizations; and, financial sustainability.

“The biggest issue with vendors in this space is who owns the data. That’s the fundamental question driving this notion of disintegration,” said Vengco. “Interoperability should be free,” according to Vengco, who understands that it’s reasonable for vendors to charge an upfront fee to create interfaces between the respective databases (of the electronic health record and the HIE). However, Vengco takes issue with vendors’ ongoing “transaction” fees. “Even if they’re charging 25 cents per transaction or upwards of $2.00, that can be very financially burdensome on five- or 10-, or 50-doctor practices. That’s $150,000 to $200,000 a year,” he said.

Kansky says that vendors always charge a one-time fee to build interfaces and ongoing fees to maintain those interfaces, but notes that not all vendors charge per-transaction fees. “The services we provide for customers [don’t] result in per-transaction fees from their vendors because [the exchange] maintains the data repository and provides [for] the sharing of data from the repository.” He notes that while his organization doesn’t charge transaction fees, it does charge provider organizations a subscription fee.

Distrust among providers and competitive pressures are also at play. Vengco says that providers are worried other doctors will lure away their patients. The best way to succeed in this environment is to educate doctors about what it means to have access to data, advises Vengco.

Then, of course, there are the fundamental economics of HIEs. Paul Chang, MD, professor and vice chairman of radiology informatics at University of Chicago School of Medicine, questions the financial sustainability of today’s HIEs—as do Kansky and Vengco—largely because of the need for ongoing funding to keep them up and running. “The cloud approach [with HIEs] is very expensive, and that’s a major barrier. There’s no way to justify it economically. Successful projects are constantly fed by the government or demonstration projects; that’s not scalable,” said Chang.

The Future of HIE

 Paul Chang, MD, Professor and VP of Radiology Informatics at University of Chicago School of Medicine

Paul Chang, MD, Professor and VP of Radiology Informatics at University of Chicago School of Medicine

The timing for “electronic health information exchanges”—a term Chang prefers to use when describing the cloud-based approach to centralized storage of patient data across provider organizations—is off, meaning the US healthcare system just isn’t ready to fully utilize them. He is also critical of today’s HIEs because it can be difficult to match a particular patient with their records on HIEs. HIEs in Europe and Canada have been successful in large part because their patients have unique IDs assigned to them by the government, so it’s easy to match patients with their records, according to Chang.

Secure electronic “point-to-point” transmission of patient data would better suit the needs of today’s healthcare organizations and their patients, says Chang. He advises providers to determine the healthcare organizations that typically request patient information—largely for referrals—and figure out how to transmit patient data to these providers securely.

Over the next few years as accountable care organizations (ACOs) start to become fully responsible for defined patient populations and there is more consolidation in the hospital and physician practice market, HIEs will become more viable. This is because ACOs will have a vested interest in funding them, according to Chang. He asserts that patients served by a particular ACO could receive unique IDs associated with that ACO. While those unique IDs wouldn’t work outside the ACO, they would make it a lot easier for patients to be matched with their digital health records when seeking treatment within the ACO’s provider organizations.

The next stage in the sharing of patient information would be akin to initiatives undertaken by Google Health (which was retired by Google in 2012) and Microsoft HealthVault to help patients store their own healthcare information securely online, says Chang. He envisions a future where patients will carry a card that a healthcare organization would use to access their health records and also update those health records with new information such as MRI findings or lab results. Provider organizations accessing and updating these patient records would pay a small transaction fee to do so, according to Chang.

Hospitals are already spending $10.00 to $15.00 each time they have to upload information from a CD into their own systems. Chang projects that hospitals will begin to look at the amount of money they’re currently spending on this and realize it is better to pay to access this information via patients’ personal health records.


Aine Cryts is a contributing writer for AXIS.



  1. Despite The Spread Of Health Information Exchange, There Is Little Evidence Of Its Impact On Cost, Use, And Quality Of Care. Health Affairs. March 2015 vol. 34 no. 3 477-483.