The State of the HIO

For the first time, more than half of community-based health information organizations are reporting a positive return on investment, while at the same time struggling to find a sustainable business model, according to the 2008 Fifth Annual Survey of Health Information Exchange at the State and Local Levels.

The findings from 130 initiatives in 48 states continue to make the case that health information technology has the capability to improve patient care while reducing costs, but also points to significant problems that continue to plague start-up HIOs, most notably, and perhaps predictably, interoperability and funding.

The funding dilemma
About 80% of HIOs say that finding the seed money to get started was their greatest challenge. The biggest financial contributors are hospitals and the federal government. About half of operational efforts received up-front funding from hospitals with the other half receiving funding from the federal government. Hospitals also topped the list for providing financial support for continuing operations. Sixty-two percent of operational health information exchange initiatives are receiving funds from hospitals to support ongoing operations, followed by physician practices (38%), the federal government (36%), private payers (29%), state government (26%), and public payers (24%).

It was a non-profit organization that provided the seed money for what is considered a model of success for other HIOs. At its inception, CareSpark faced many of the challenges other HIO start-ups say they are facing now. The Kingsport, TN-based exchange sees about 750,000 patients from five different states, and therefore has to contend with five different state Medicaid programs, five different state health plan systems, and innumerable health information systems. "You could say we were the perfect storm of collaboration and consistency. We realized it is very important that we would have to be able to coordinate and communicate with many others in the country," said Liesa Jenkins, executive director of CareSpark during a briefing held by the Capitol Hill Steering Committee on Telehealth and Healthcare Informatics.

Now, after five years in operation, CareSpark is being used as prototype for HHS's National Health Information Network program, which will perform a technical and interoperability and standards demonstration on September 23, according to Rob Kolodner, MD, national coordinator for health information. "We will demonstrate NHIN using standards and agreements that form the integrated delivery networks, and when these NHIN networks go into production in 2009, we will make a true network that will evolve into a network of networks. It's by matching that innovation with consensus-based standards that we will foster the forward movement of the nation to transform healthcare," he said during the Telehealth and Healthcare Informatics briefing.

The growth of a movement
There is some proof that that "network of networks" is on its way to forming with 42 operational health information exchange initiatives. That number includes 18 new health information exchange initiatives, which the study's authors say is evidence of the increased interest in the use of health information exchanges. The number of health information exchange initiatives in each phase of development is evenly dispersed. Thirty-nine of the initiatives included in the 2008 survey are just getting started with health information exchange, 36 are in the process of implementation, and 42 are operational.

Reporting ROI
A majority of the operational HIOs said stakeholders were getting positive financial return on the investment in the exchanges. Thirteen said they could quantify a return on investment for hospitals, nine reported ROI for medical practices, six reported ROI for health plans, and five reported ROI for independent laboratories. In some cases, more than one class of stakeholder was getting ROI, the findings show.

Janet Marchibroda, chief executive officer of the eHealth Initiative and eHealth Initiative Foundation, says part of the reason that some of the HIOs are seeing positive ROI is a better understanding of health IT among the various stakeholders. "The field is maturing. These initiatives are now operationalizing their services, which makes achieving ROI attainable. Also, the notion of health IT adoption and health information exchange across various stakeholders in the system is more accepted than it was two or three years ago. Bipartisan support within Congress, the federal government's leadership in supporting trial implementations of health information exchange, and efforts in the private sector related to health information exchange—including those supported by eHI and others, such as the National Governors' Association, are helping to bring stakeholders to the table to engage, to trust, and to begin to utilize ‘services' from these initiatives that deliver value, and ROI to various stakeholders," she says.

So what are the challenges?
The most significant challenge for all 130 efforts in the study continues to be the development of a sustainable business model, with 50% of respondents characterizing this as a very difficult challenge, followed by securing up-front funding, with 47% saying this is a very difficult challenge. Marchibroda says both of these challenges are related to the current reimbursement system, which provides disincentives for the sharing of health information to support improvements in care.

Overall it was a mixed bag of results for the HIOs in this year's study. There were some clear advances made, but there were just as many, if not more, challenges reported. As a panel of speakers at a Capitol Hill Steering Committee on Telehealth and Healthcare Informatics briefing to discuss the study was quick to point out, we are still miles away from the reality of creating a National Health Information Network. "We're making a lot of progress, but the federal government must stay active and provide the leadership for health IT," Kolodner said.