Not too long ago, health information exchange - the verb, not the noun - was something someone else had to worry about. It was complicated, sometimes contentious. But many providers could sleep well, comforted by the fact that it was large hospitals and academic medical centers - not them - who were the ones dealing with it.
Everyone from Office of the National Coordinator on down have been paying close attention to parts of speech when it comes to health information exchange lately. Quoth Farzad Mostashari, MD: "I refuse to speak of HIE as a noun. HIE is a verb."
But no question, the mechanisms of HIE are very much nouns - and very different types of nouns, at that.
There are private HIEs: "I'm the hospital and we own a bunch of doc practices and some of them run one brand and some of them run another, and we bring their data into a central repository," says Hoyt. There are public HIEs: "There is some sort of a neutral entity to which we all subscribe somehow, and we send the data to it - it's the broker, it sends it to the requesting organization, or to all organizations."
There's also a third category, "which has been around for a while," says Hoyt. "I'd argue that it's not quite in the spirit of what health information exchange is. It's organizations who electronically participate, by law in some immunization registry or disease registry."
But for these purposes, health information exchange refers to a public or private mechanism that shares data in order to "help improve the continuity of care."
Public and private models, of course, are inherently different in conception, funding, and, perhaps most consequently, staying power.
Which is best positioned to thrive in the long-term?
"Boy, that's the ultimate question," says Hoyt. "The public is going to have to have some sort of funding mechanism to keep it alive. Everybody wonders what's going to happen when the feds say, 'OK, we've given you enough money for enough years. You're on your own.' There is serious question whether they'll build a business model that will keep them alive."
And what if many of them fall victim to lack of revenue?
"The next question - and this is all theory - but if a bunch of them sit down because they all went broke, does the federal government recognize, 'Oops, we're not getting the continuity of care that we want,'" and toss some more money at them?
On the other hand, of course, "The feds could say, 'Don't worry about it, I only deal with ACOs, which have private information exchanges.'"
And make no mistake, says Hoyt, for all the terrific state-level HIEs out there, "There are some great examples of privates." For one, he points to Adventist Health System, in Florida, which enjoys a "VERY robust exchange," in more than 40 hospitals, from Wisconsin to Miami.
"All of those hospitals have relationships with physicians in their communities, with whom they are exchanging information. You could be a physician in Appleton, Wis. today, and tomorrow you're in the ED in Orlando, and you can get the data. That is impressive."
Pam Matthews, RN, senior director of regional affairs at HIMSS, says, "We are seeing another evolution," in HIE.
"Public exchanges - the most noteworthy are the state HIEs - that came through the ONC funding out of HITECH," continue to grow and evolve. Some more than others, of course.
"We are seeing states, where some are not as aggressive, we are seeing some being very aggressive in establishing a state-level HIE," says Matthews. "They are either established under the auspices of the state, or they can actually identify their state-designated entity."
On the other hand, "We also are seeing some states that are using Direct, and are looking at other options instead of actually setting up a full-fledged state level HIE," says Matthews. "There are various flavors that are materializing. Each state has its geographic market drivers, as well as political drivers. The states have to look at what their market and political environment will bear."
She adds: "I will tell you, states are eager to share, they're eager to learn from each other."
Still, says Hoyt, "I think the trend lines going forward will be creation of regionals on a private basis. If the state is not acting quickly enough, the hospitals have to be able to demonstrate that they can do health information exchange for Stage 2: 'If we're going to have to do that, why don't we just build one with the docs that are serving us?'"
"My own guess, is I would still bet on the privates."
However the next few years shake out, there's no mistaking how far things have come in the past few years.
"We've made great strides, and we will continue to," says Matthews. "We will continue to see advancements in technology, and a lot of those advances over the next five years can be leveraged by organizations exchanging data, [so] it can be accomplished more easily and efficiently."