Is the number of HIEs declining nationwide? Yes, but that’s not necessarily a bad thing.

A few months ago, Health Affairs, a leading journal of health policy thought and research, published an article by Dr. Julia Adler-Milstein and colleagues that found that the number of health information exchanges is declining. That’s true. But it doesn’t quite tell the whole story. Read the letter to the editor by John Kansky, IHIE’s president and CEO, that suggests a different perspective.

Numbers of Health Information Exchanges

John P. Kansky

Julia Adler-Milstein and coauthors (Jul 2016) found that the number of health information exchanges (HIEs) is declining, which potentially limits the broad exchange of clinical data in the future. I am not surprised that the data indicate that there are fewer HIEs. However, I believe that this decline is at least partly explained by HIE consolidation. The article reports a decrease in operational HIEs from 119 in 2012 to 106 in 2014. But it also acknowledges that 7 HIEs merged, which explains 31 percent of the total reduction in HIEs. A consolidation trend in HIEs has been expected, as small- and medium-scale HIEs have sought economies of scale to offer higher value at lower prices.

In addition, more important than the number of HIEs is the number of patients and health care markets that HIEs serve nationally. I suspect that while the total number of HIEs has fallen, the number of health service areas (HSAs) served by those HIEs may have grown. That would suggest that HIEs are getting bigger, covering larger regions, and serving more providers—not fewer. This is true in Indiana, for example, where the Indiana Health Information Exchange has added at least five new HSAs to its service area since 2012.

As follow up to Adler-Milstein and coauthors’ research, I suggest an examination of whether the number of HSAs served by HIEs has increased over the same time period that the number of HIEs has decreased.


Health Information Exchanges: The Authors Reply

Julia Adler-Milstein and Sunny C. Lin

John Kansky’s letter about our article (Jul 2016) raises an important new dimension that should be used to evaluate the progress of health information exchange (HIE) efforts in the United States. Indeed, the total number of efforts is a much more useful measure when accompanied by the levels of geographic coverage and provider engagement achieved by those efforts. We reported the numbers but did not perform a longitudinal assessment to determine whether the current HIE efforts are expanding their geographic coverage.

If we compare the total number of health service areas (HSAs) covered by operational HIE efforts in 2012 compared to 2014, coverage rose from 1,862 to 2,028. More relevant to Kansky’s point, the average number of HSAs covered per HIE effort rose from 24 to 36. Another interesting point of comparison is that the percentage of HIE efforts reporting full state coverage increased. In 2012, 15 percent of operational efforts reported state-level coverage (with 30 percent of states fully covered). In 2014, 30 percent of operational efforts reported state-level coverage (with 70 percent of states fully covered). This is consistent with Kansky’s hypothesis, and we share his interpretation that this is a positive sign for the sustainability of these efforts.

More broadly, we agree that consolidation is to be expected as the HIE industry matures, and it is encouraging that we are seeing consolidation instead of unsustainable HIE efforts simply disappearing. However, we continued to see a substantial fraction of operational HIEs that reported sustainability challenges. With the growth of alternative approaches to enable HIE, we think that it continues to be critical to monitor these efforts and understand how they are faring.