Because state-level HIEs employ different models and offer different
services, it is difficult to fit them into the meaningful use program.
Some states, like Delaware and Vermont, are developing
state-level HIEs that act as a one-stop spot for all information
exchange in the state. Though this works for smaller states, the
model is not appropriate for larger states like California that already have several regional health information exchange organizations in place.
California’s state-level HIE model works as an umbrella coordinator that implements exchange and security standards and
offers policy and financial support to the various regional information exchanges.
Several different HIE models have emerged, and services the
different state HIEs provide also vary. Forcing HIEs to develop
in a certain way would lead to their demise, Williams says. Instead, ONC has allowed the HIEs to identify how they can add
value to their healthcare marketplace and institute services specific to their regions.
“It is the job of the HIE grant program [awardee] to look at its
own environment and think about how you use these grant re-
sources in the most value-added way,” she says. “And that is go-
ing to vary from state to state.”
Though the approach has slowed down the launch of some
HIEs, ONC deserves credit for its extensive work creating plans
for each state’s environment, Frohlich says.
It is up to the state-level HIEs to decide to implement Direct
and NwHIN Exchange standards.
CareSpark, an HIE serving northeastern Tennessee and southwestern Virginia, is testing Direct in the exchange of mammography orders and test results between the local Veterans Affairs
facility and private sector providers.
If the pilot is successful, CareSpark expects to add Direct into
its suite of HIE services, according to Susan Torzewski, RHIA,
CareSpark’s EMPI administrator.
Direct shouldn’t be seen as a competitor to an HIE, Torzewski
says. Even providers who use Direct will still need HIEs to facilitate more advanced exchanges.
Whether Direct arrives in time to help providers meet the first
stage of meaningful use objectives is another question. Direct is
not expected to be available for widespread use until 2012. The
next stage of the program begins in 2013, and it is expected to
include requirements for information exchange that are more
complex than Direct is intended to provide.
More coordination between the various HIE efforts is needed
to speed up HIE development, Frohlich says. If these projects
continue along their current trajectories, they will continue to
drift apart and hamper their connection into a workable HIE
Most state HIEs will leverage Direct and NwHIN specifications
even if they are not required to do so, Torzewski says. It is in their
best interests to align with the nationally produced specifica-
tions to standardize their operations. [For more on CareSpark’s
pilot of Direct, see the article “Direct Results” on page 38.]
State-Level HIE and Meaningful Use Disconnect
Some critics say that in order for HIEs to even be in a position
to offer Direct or NwHIN Exchange, they need solid, long-term
support from local providers who would actually use the exchange. The start of this local support network should come in
part from participation in the meaningful use program, critics
state, which to date has included few requirements that cause
providers to use their state HIE to achieve meaningful use requirements and get incentive payments.
“There is too remote of a connection between what is being
funded through the state HIE grant program and the meaningful
use criteria,” says Bill Bernstein, the healthcare division chair at
law firm Manatt, Phelps & Phillips. Bernstein counsels numerous states, providers, and companies on healthcare information
infrastructure and health IT public policy issues.
As stage 2 meaningful use is developed, some HIE advocates
have called on ONC to increase the amount of health information exchange criteria required in the program in order to more
directly support state-level HIEs.
Information technology advocacy organization eHealth Ini-
tiative (eHI) said in comments submitted to ONC in February
that stage 2 meaningful use objectives need an “increased focus
on health information exchange.”
“eHI supports the ability of eligible providers and hospitals to
meet the Meaningful Use requirements through the use of HIE,
yet Stage 2 requirements remain focused on electronic health
records and do not allow providers enough room to utilize HIE
as a means to meet Meaningful Use requirements,” eHI wrote.
Millions of dollars are going to be issued to providers for meeting meaningful use targets, and that money should in part ride
on a provider’s use of the state-level HIEs, Frohlich says. This
could be done by allowing providers to achieve meaningful use
requirements by directly reporting information through their
“If those meaningful use targets are heavily dependent on
HIE activities, then what the market would tell you is there will
be more attention to purchasing and implementing HIE solutions, which should be born from the HIE cooperative program,”
Frohlich says. “If the meaningful use criteria are light on HIE
and have minimal requirements, in many respects there is not
a lot to drive adoption of the HIE services that are being built by