As already discussed in earlier posts, the eHealth Initiative has published a series of annual reports on the progress of RHIOs across the United States. The most recent report, "Migrating toward Meaningful Use: The State of Health Information Exchange" presents the results of the 2009 Sixth Annual Survey of Health Information Exchange. A review of this report reveals some serious methodological considerations affecting interpretation of study results. Current U.S. policy for health care system reform is founded on the proposition that emerging RHIO networks will coalesce into a national health information infrastructure for HIE. There still is no evidence base to substantiate this proposition, and as pointed out earlier, there is no business model for development of sustainable RHIOs.
The summary results of the 2009 survey claim a 40% increase in the number of "advanced or “operational” initiatives exchanging information," as well as positive impact on efficiency of care and return on HIE investment. Evaluation of the sample described in the full report shows however that the increase in number of initiatives (n=150 organizations - up from 130 in 2008) is based on a shift in the earlier sample. In the report section on study methodology, it is stated that 344 individuals responded to the survey announced through a variety of media and incentivized with $10 Starbucks Cards. It is not clear how these individuals were qualified to respond to survey questions, and there was no control for variance in responses due to different positions held by respondents. After review of responses received, 150 HIE initiatives were judged valid to be included in the analysis although there was no systematic verification of information provided by individuals completing the survey, and no uniform definition of an HIE initiative.
Although authors of the study attempted to obtain responses from all organizations responding to the survey in 2008, only 66 of the earlier sample responded in 2009, while 84 (more than half) of the 2009 sample were new respondents. This shift indicates a highly significant "mortality" rate among HIE initiatives which is not even addressed by the study authors - except as they state that 43 of these initiatives appear to continue their pursuit of HIE. Such "mortality" may suggest the lack of sustainability in business model design. Some of the data presented seem to corroborate this interpretation. While public funds seem very significant in initial HIE start-up (See figure 12.) - including federal, state and local government grants and contracts (n=99) - private payers contribute to start-up much less frequently (n=26). Ongoing sources of revenue shown in figure 13 indicate the withdrawal of public sector funding. This pattern is particularly interesting in light of the exchange of data for insurance enrolment, claims, and eligibility determination (See figure 9.). HIE seems heavily focussed on the management of the financial dimension of health care (n=52). While public funding is mobilized for HIE start-up, the private sector appears to benefit disproportionately from services offered. For example, the Utah Health Information Network is well developed for coordination of information for payers, but offers virtually no clinical services at this time. This network is also characterized as "uniquely Utah", with no provision for future linkage outside the state.
The Directory of Health Information Exchange Initiatives offers a useful database for further examination of emerging RHIOs.
CCHIT has made available a presentation of its New 2011 Certification Programs, including HIE, but there is increasing recognition of the need for a national health information infrastructure. There will be much waste in certification fees paid for an uncertain and ill defined process. Without necessary and sustained public investment in infrastructure, the promise of health information exchange across the U.S. will remain unfulfilled. While some experts and lobbyists claim that this promise will be realized within a time frame of two years, many understand that the ideologically charged debate concerning infrastructure design and implementation will probably extend well beyond 2014. Unfortunately for American patients and taxpayers, many business opportunities reside in the prevailing confusion of future scenarios for U.S. health care reform.