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Government Regulation Hinders Public Health Information Exchanges

Funding uncertainty and healthcare providers' concerns about security and efficiency also contributing to slow growth of public exchanges, finds KLAS study.

Likely due to issues around governance and funding, growth in private health information exchanges has far outstripped that in public exchanges, according to a new report, Health Information Exchanges: Rapid Growth in an Evolving Market, by healthcare vendor monitoring firm KLAS.

Since 2010, the number of live public health information exchanges rose from 37 to 67, while the number of live private health information exchanges mushroomed from 52 to 161.

Regarding governance, the KLAS report found the complications inherent in government-sponsored initiatives--and the difficulty of getting competing healthcare organizations to agree on what to share--hamstring public health information exchanges.

"There are some states where the largest integrated delivery networks (IDNs) are not even participating in the state HIEs because, quite frankly, they view patient data as an asset. They ask, 'What do we have to gain by exchanging this information?' So until the state can make those key IDNs completely comfortable, they will hold out," said Mark Allphin, clinical research director with KLAS and author of the report.

Private health information exchanges need not depend on public or government oversight.

In terms of funding, KLAS states that though there are currently numerous grants and funding options available, providers are very concerned that public monies may dry up at any time, leaving them without the means to continue functioning.

According to survey respondents, physicians may be contributing to the lag in deployment of public health information exchanges. Providers reported that doctors are interested in health information exchanges, but not if they cause them to lose time searching for or wading through too much patient information.

"Across the board, when we speak to information exchanges they say that if you don't put the data into the natural workflow of the physicians, adoption will suffer," said Allphin. "Even going one extra place, if it takes an extra two or three minutes per patient, it will deter them--that adds up in a hurry."

But getting data in the right place usually requires an interface from the health information exchange to the providers' electronic medical record (EMR)--and that can mean big bucks. Allphin said such interfaces can run in the tens of thousands, certainly prohibitive to all but the largest health systems. To offset that burden, he said, many public health information exchanges are offering cash--such as a $2,500 'interface' payment.

Concerns over data integrity and having outside providers push data into physicians' EMRs were also voiced as contributing to the low adoption of public health information exchanges. Many, says Allphin, are far more comfortable with "hard" data, such as lab values and radiology images, rather than readings or other forms of interpretation. "I know what I put in my medical record, but as soon as other information is coming in there, I'm nervous about that. I'm nervous about liability."

While most issues around health information exchange development focused on business and liability issues, technology challenges did surface. The Continuity of Care Document (CCD) seems to be the ideal choice for information exchange, but many EMRs are not ready to send and receive them, accord to Allphin. "Many told us, 'My EMR can package a CCD but not send it, or my EMR can't receive and display them,' This is still very much of a technical barrier."

In the case of private health information exchanges, Medicity, RelayHealth, and Cerner ranked highest in performance scores. Although Epic Care Everywhere scored higher than all three, Epic was not ranked in the report because nearly all of its exchanges KLAS was able to validate were between Epic hospitals, according to KLAS. One Epic health information exchange was with a non-Epic EMR system. In the case of public health information exchanges, both Axolotl and Orion scored 83.8 and 85.5, respectively. However, neither system was ranked in the report because they did not meet the minimum KLAS Konfidence levels, KLAS stated.

More than 230 health information exchange customers were interviewed for the study. Together they evaluated a total of 35 HIE vendors.

Anthony Guerra is the founder and editor of, a site dedicated to serving the strategic information needs of healthcare CIOs. He can be reached at

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