Are we witnessing the death of public HIEs?

There's been a lot of press about Black Book Rankings' latest study of health information exchanges (HIEs) and how so many providers still are not participating in them.

But perhaps a more important and far-reaching finding from this report is that providers and prayers are shifting away from community, public HIEs and moving toward private ones, which Black Book dubs the "replacement revolution."

The study notes that nearly 94 percent of payers intend to abandon their involvement with public HIEs and create and/or bolster a private one. Almost four-fifths of providers (79 percent) corroborated that public HIEs and electronic health record-dependent ones were "disenfranchising" the payers.

Ninety percent of hospital respondents also saw private HIEs as potentially more profitable.  Both providers and payers were frustrated with vendors' inability to provide interoperability and with the Office of the National Coordinator for Health IT for failing to deal more harshly with the vendors.

And when you delve into the weeds of the actual report, the findings become even more striking.

  • Private HIEs continue to outpace public HIEs. There were 277 sustainable private HIEs in 2015 compared to 152 in 2014. In contrast, 83 percent of the nation's 165 public HIEs are failing despite some funding to shore them up. 
  • Almost all (98 percent) of healthcare organization decision makers believe that private HIEs are the preferred choice to achieve accountable care organization (ACO) deliverables. Only 2 percent of ACO managers find operational public HIEs capable of meeting their data requirements.
  • Many public HIEs have not yet figured out how to fund themselves now that the $548 million in HITECH money that supported their start-ups has run out.
  • The commercial payers, who can benefit the most from HIEs but haven't participated much yet, are investing in private HIEs and "snubbing the bureaucracies, fees and complex architecture of government sponsored HIE," which is compounding the public HIEs' sustainability problem.

And all of this as the HIE will "dramatically change" in the next two years as providers turn to better data sharing to meet Meaningful Use and payment reform requirements.

It appears we know how it's changing: from public to private HIE.

This shift is pretty powerful. Look at what the providers and payers are doing. Long known to be more adversarial than allies, they increasingly are willing to dance together to make value based payment work. And they're signaling that they're going to do it their way: with the private HIEs that they believe will best help them do that.

They're saying that two models of HIE, which the survey points out "complicates" HIE strategic development, aren't necessary. They're tired of being dictated to, of waiting for public HIEs, vendors and the government and "government-scripted vendor pledges" to make it work. They're taking matters into their own hands.

While fascinating, this also raises several questions. For example, what does this say about the effort--in many ways unsuccessful--to support and maintain public HIEs? Was it a failed experiment? Was it all a waste of money and effort? If so, how was that allowed to happen?

And what does this mean for the future of HIEs and interoperability? Are private HIEs simply larger silos? How does this rectify the overall problem of national data exchange?  

Additionally, what does that say about the government? Did it make the right decisions when it opted not to regulate HIEs and dropped the idea of a national health information network? Or does this impact ONC's credibility right at the time that it's trying to reposition itself in a changing world?

There have been recent glimpses that public HIEs were floundering. If the private sector is turning away from them in droves, does that mean that their demise is inevitable?

It's not necessarily a bad thing for the landscape to be shifting. But everyone seems to be focused on the Triple Aim of reducing costs, improving the patient experience and improving population health. We can't overlook those who provide and pay for that care and the kind of support systems they need to do that. - Marla (@MarlaHirsch and @FierceHealthIT)