While "persistent challenges and barriers" related to infrastructure and funding continue to vex state health information exchanges, there's still ample need for their services and plenty of opportunity at the state and federal levels to keep supporting them, according to a new report presented to ONC.

[See also: Sustainability a challenge, state HIEs join forces]

Conducted by the National Opinion Research Center at the University of Chicago, the study takes a close look at the experiences of Iowa, Mississippi, New Hampshire, Utah, Vermont and Wyoming since they received their slices of the $564 million provided by ONC's State Health Information Exchange Cooperative Agreement Program in 2009.

Beginning with case studies in 2012 and 2013, NORC's report – "The State HIE Program Four Years Later: Key Findings on Grantees' Experiences from a Six-State Review" – examines key enablers, challenges and lessons learned.

[See also: State HIEs prep for disaster recovery]

Most state HIEs have pursued a two-part strategy of enabling both directed and query-based models to share data, the study shows. Care summary exchange, lab results reporting and exchange, public health reporting and transmission of admission/discharge/transfer messages, are among the most common capabilities.

But various exchanges differed in their technical infrastructure, NORC finds, with some choosing federated models to emphasize data security, and others opting for centralized infrastructure to enable population health management and analytics.

Decisions on infrastructure and service offerings were based on a variety of factors, according to the report, especially the short- and long-term needs of local stakeholders, cost and infrastructure security. Meaningful use also affected most exchanges' decision-making processes.

As for ensuring sustainability beyond the initial batch of HITECH funding, some states "found that marketing their services to ACOs, or requiring ACO participation in state-led services, can bolster demand and participation," according to NORC.

Financial incentives for providers, such as meaningful use, have also helped, as have state-level laws requiring participation. The report shows how some states required legislative action to bolster privacy protections and get rid of more systemic barriers to exchange.

The big takeway, according to NORC, is that "stakeholder buy-in – philosophical and financial – proved critical to HIE success. The more parties supported, promoted, and participated in HIE, the easier the implementation path."

Collaboration with Medicaid, the regional extension centers and ONC were also key to getting optimal buy-in.

HIEs have been beset by challenges in recent years, of course. The report finds that one key to success was for organizations to set "tangible, intermediate goals that kept stakeholders energized by ongoing progress. Moreover, grantees found that defining incremental processes and goals allowed them to make course corrections when necessary."

Stakeholders in all six states reported IT-related challenges, from EHR and HIE vendor limitations to lack of interoperability between systems and data capture and quality issues. To address the former, some HIEs shifted to a best-of-breed approach, NORC reports, working with multiple HIE developers for different needs.

As for interoperability, "many HIEs look to the ongoing development and adoption of data standards as the long-term solution. In the short term, grantees are encouraging the use of certain standards among their participants and building capability in data translation and in-house teams responsible for data cleaning."

For sustainability, HIEs "are embracing the central tenant of providing value-added services," according to the study. "For many, this involves focusing on Stage 2 meaningful use exchange requirements and aligning their service offerings with payment reform priorities, such as care coordination."


NORC adds that, "with the conclusion of the State HIE Program and sweeping changes to the healthcare system, there are a number of opportunities at the state and federal levels to continue supporting HIE services." Among its findings:

• The State HIE Program highlighted the important role states play in leadership and coordination, particularly in convening stakeholders, policy development, and needs assessment, which will be relevant to future stages of meaningful use and health care reform.
• There is a critical need for strong, ongoing support related to standards and interoperability.
• A provider- or federal-led effort to obtain buy-in from HIE developers for overarching HIE goals may be warranted and needed to change perceptions of interoperability.
• There is a need to assess how technical solutions evolve in different markets, to develop and disseminate best practices, and to develop governance and oversight requirements at a state and national level.
• Organizations should monitor findings and best practices for sustainability from existing federal and state level initiatives leveraging pay-for-performance models.

Read the full report here.