Very few in healthcare argue that exchanging patient health records electronically is a bad idea. HIEs around the country are already touting the benefits of their services, namely a reduction in unnecessary patient trauma and unnecessary costs.
One HIE director in San Antonio recently wrote an Op-Ed in the San Antonio Express News about HIEs , saying that 85% of local patients are in favor of a system that securely exchanges their
health information, yet only one of four physicians in the San Antonio area uses an Electronic Medical Record (EMR), as defined in Defining Key Health Information Technology Terms (The National Alliance for Health Information Technology, April 28, 2008): An electronic record of health-related information on an individual that can be..., despite a significantly higher hospital adoption rate.
The point of his article was twofold, in my opinion: to increase Health Information Exchange (HIE) focuses on the mobilization of healthcare information electronically across organizations within a region or community. HIE provides the capability to electronically move clinical information between disparate health... awareness among the local community, and to call to task physician practices who are ignoring the demands of their patients and holding back the current evolution of the healthcare system.
The San Antonio example is a good illustration of why many believe Health Information Exchanges face an uphill struggle for existence.
Obstacle one for HIEs: Become financially solvent.
In 2011, there were 255 HIE organizations in the U.S., yet only 24 reported that they were financially sustainable. In other words, there are 231 HIEs that are currently not making enough revenue to cover operating expenses.
Many of these HIEs are able to continue operation due to HHS grants and because member healthcare organizations are willing to risk a short-term financial loss because they believe the HIE will gain widespread provider acceptance, which will eventually help them recoup early losses through several cost savings measures and future government reimbursement incentives (e.g., bundled payments, quality of care benchmarks).
Local physician practices are slow to adopt EMR systems due to significant costs that can outpace Meaningful Use  reimbursements and, some would argue, because they have no financial incentive to enthusiastically adopt a new healthcare system that moves away from the fee-for-service model they have successfully used for generations. From strictly a business sense, it’s logical for them to ask “What’s in it for me?” before investing hundreds of thousands of dollars on an EMR system just so they can connect with the local HIE.
Like the San Antonio example above, HIE directors must prove to the referring physician community that patients overwhelmingly want a system that securely exchanges their medical data, and that belonging to such a system will provide the physicians a return on their investment of an EMR system with external connectivity, HIE fees and all the additional technology and staff required to make it functional.
Through Meaningful Use and HHS, the government is also playing a major role in pushing all providers toward a modern, electronic medical system. However, time is of the essence for HIE sustainability and there are no government mandates that require participation in an HIE, regardless of the obvious benefits it has for patient care. The recently released proposal for Stage 2 Meaningful Use has objectives which might push eligible professionals to utilize an HIE, but those rules are not effective until 2014.
Obstacle two for HIEs: Patient Education
An HIE can have 100% provider participation, but it is worthless if it doesn’t have patient data to exchange. It’s imperative that HIEs receive patients’ consent to exchange their health data with other HIE provider members. HIEs currently employ two different models: the patient opt-in model or the patient opt-out model.
It’s pretty simple. When visiting their provider, patients are given two options about their patient data, usually in the form of a check box on paperwork that is completed during check in, which sounds similar to the following simplified examples:
- Check here if you approve Memorial Hospital to share your electronic health record with local health providers who are members of the State Health Information Exchange. (Opt-in Model)
- Check here if you DO NOT want Memorial Hospital to share your electronic health record with the State Health Information Exchange. (Opt-out Model)
HIEs have found that the Opt-out Model has a higher success rate because the patient must take the extra action to exclude their record. The Opt-in Model requires an extra educational component about the benefit of HIEs for the patient, either in the form of printed materials or by verbal communication from the office staff.
The Opt-in Model also has other obstacles to gain patient consent because there is an inherent distrust by many Americans to allow their information to be used for any purpose because it only reminds them of junk e-mails, identify theft, and telemarketing phone calls.
So, despite great interest in HIEs, they have many obstacles to overcome before they can claim to be successful. However, numbers never lie – if operating HIEs continue to report progress on cost savings and patient safety, then it is unlikely provider organizations will want to be on the outside looking in. Patients realize the health system is rapidly changing and soon they’ll have the choice to go to a provider who has invested in modern technology in an effort to provide better patient care.
Topics in this HIE series include:
Part 1: Health Information Exchange: What’s the Motivation? 
Part 2: Architecture Types 
Part 3: Despite Momentum, HIE Sustainability a Concern 
Part 4: The Building Blocks of HIEs: A Glossary of Terms 
Part 5: HIE Communication Methods 
Part 6: HIE Physician and Patient Portals