Transitioning from patchwork to quilt: NY and PA’s path to integrating HIEs at the state level

The state planning efforts share some key parameters:

Beyond those parameters, however, the plans look quite different.

NY’s approach: Start in NYC, then head upstate, adding HIEs as they go NY’s plan appears to be more specific
in its outcomes, aiming to add in service after service and HIE after HIE based on demand and the situation on the ground. It is able to do this because it has geographically compartmentalized its HIEs.  PA, in contrast, is trying to take big leaps forward driven by the state.

PA’s approach: First connect the current infrastructure already in place; presumably, as the state-level network emerges, local
provider stakeholders will see enough value to initiate provider richer coverage.

Why so different?  The starting point for these plans is the existing HIE infrastructure where there are dramatic differences between the two states:

Most of NY’s local HIEs established themselves between 2004-2006 and have developed their infrastructure more than PA’s HIEs. NY was also historically more aggressive in seeking and using public funding, securing $400M in investment funds. Furthermore, NY local HIEs tend to focus on a particular geography and are “open” or “public” (in the sense that they are being managed by and sharing data across unaffiliated providers). The public HIE model tends to remove data exchange, as it is a source of competitive advantage for providers. The table below shows NY’s current HIE infrastructure.

In contrast, most of PA’s HIEs established themselves much more recently in the 2008-2011 timeframe. They also tend to be centered on a hospital system and more “private” (being managed by an integrated bloc of providers). Many of these programs have been exclusive, rejecting providers who have applied to join them. Even some HIEs that describe themselves as being open to any and all providers (e.g. Pittsburgh’s Clinical Connect or the Highmark Community HIE), are still aligned with one major provider (UPMC or West Penn Allegheny). A couple PA HIEs even straddle this divide of public/private by offering free HIE services to their aligned providers but charging unaligned providers premiums to take part.

By creating an advantage in access to information, private HIEs can create competitive advantages for providers. While this can make sustainability models easier for an HIE (who won’t pay something for an advantage), it can make integrating across local HIEs more difficult.

Perhaps given the initial public funding, NY local HIEs appear to offer strong coverage in the most populous areas (e.g. 6 HIEs in the NY metro area). In the first roll out of SHIN-NY 2.0, NY is integrating the HIE’s programs for patient record lookup and direct exchange between clinicians. Eventually, they will add more functionality into the system. In contrast to these public HIE models, private HIE models depend on providers believing they can extract advantage based on the local market structure. Perhaps for this reason, the HIE coverage in Philadelphia is very sparse.

A look at the boards of NYeC and PAeHI reveal a difference in power structure. In NY, IT consultants, vendors, community workers, doctors, hospital administrators, state officials, payers, and the HIEs themselves all share the positions on the board. In PA, however, the board is composed primarily of state officials. Why is has PA stacked it board in favor of the state? Perhaps it is because provider aligned HIEs will avoid sharing data unless the state acts as an enforcer.

Given the prevalence of the public HIE model in NY, it is not surprising that the local HIE’s seem much more interested in expanding the data sharing. For example, 55 applicants applied for six lots in the SHIN-NY 2.0 regional extensive center program. In addition, NY has also started an Interoperability Workgroup of 12 states (covering nearly 40% of the US population) while PA has kept their focus on the state level.

(Article written by Jamie Matheson)