HIE in California

Long before the health information technology boom, California had a community-oriented, decentralized approach to data sharing. This approach continued during the HITECH era, with the development of a trust framework that provides the most flexibility to adapt to California’s complex healthcare ecosystem and emphasizes local autonomy to create and operate services that best meet the needs of local users, supported by voluntary self-governance as well as local and state government coordination.

California is one of the most diverse states in the country in terms of people, geography, and economy. Approximately 80% of California is rural, yet 85% of the population lives in urban areas, creating diverse scenarios regarding access to care in both rural and urban communities. This huge range of diversity creates a complicated and divided technology landscape. In this way, California is truly a microcosm of the entire United States, reflecting the diverse technology challenges seen on a national level.

The HIE landscape in California consists primarily of two types of health information organizations:

Community – local or community-based initiative, supported by a number of unaffiliated health care organizations, often within a geographic medical service area
Enterprise – supported by a single hospital, health system, or integrated delivery network

Health Information Organizations Trusted Exchange Consent
Community HIOs: 15
Enterprise HIOs (statewide): 4
Members of CAHIE: 17
Signatories to the CalDURSA: 12
CTEN Participants: 10
MMPA-based Participation Agreement: 10
Opt-out or hybrid
Note: California does not have a statewide consent policy or regulation


Contrasting National Initiatives

With the growing attention on interoperability and emergence of national "networks", the HIE landscape has become somewhat confusing. Below are some comparisons of the major national exchange initiatives people ask about the most, along with a contrast with community or regional health information exchange.

eHealth Exchange CommonWell Carequality Care Everywhere DirectTrust CTEN Community HIE
Provider-centric network Patient-centric network Provider-centric network-to-network trust framework Provider-centric network Secure messaging network Provider-centric network Person-centric network
Peer-to-peer primarily query-based exchange Query-based exchange based on centralized record location Peer-to-peer query-based exchange Peer-to-peer primarily query-based exchange Peer-to-peer, content-agnostic secure messaging Expanding use cases beyond query-based exchange and secure messaging Various use cases, including alerts, results delivery, order entry, query, public health reporting, longitudinal records, and analytics
Centralized provider-organization directory Centralized MPI and RLS Centralized provider-organization directory Vender-based enabling infrastructure Enabling trust framework Enabling trust framework Various levels of centralized resources necessary to meet participant needs
Governed by the DURSA, in turn managed by committee of participants Governed by Board of Directors Governed by the Carequality Connected Agreement, in turn managed by steering committee Governed by user agreement Governed by members Governed by CalDURSA, in turn managed by committee of participants Governed by Participant Agreements, usually in turn governed by a Board of stakeholders
Members are provider organizations Members are primarily EHR vendors Members are primarily EHR vendors with some HIEs Participants are providers using Epic Participants are service providers, primarily for provider organizations Participants are HIOs and state agencies in California Participants are providers, provider organizations, labs and other ancillary services, pharmacies, public health, payers, and researchers
Primary participants are federal agencies, hospital systems, large and medium HIEs Main vendors are athenahealth, Allscripts, Cerner, eClinicalWorks, Greenway, Meditech, and others Main vendors are athenahealth, eClinicalWorks, Epic, GE, NextGen, Surescripts, and others Limited to Epic users Direct HISPs and certificate authorities Organizations interested in inter-organizational exchange Systems may include nearly any EHR, lab, pharmacy, or other HIT system

eHealth Exchange and Carequality are both initiatives of The Sequoia Project. Today, eHealth Exchange provides unique access among national initiatives to exchange with federal agencies.

CommonWell is an initiative of the CommonWell Health Alliance.  Like eHealth Exchange and Carequality, health information on CommonWell and Care Everywhere arrives as a CCDA document.

eHealth Exchange, CommonWell, Carequality, and Care Everywhere are primarily driven by a single use case: query-based retrieval of a summary medical record. With all but CommonWell, information is retrieved through a query directed to specific provider organization(s). Little information is delivered outside of queries on eHealth Exchange, and CommonWell and Carequality do not have the capability for anything but query-based exchange.

Community HIE, by contrast, focuses primarily on addressing the priority use cases of the participating stakeholders through community collaboration and governance. Infrastructure is based on flexible technologies capable of supporting many technical standards and many information payloads, all through very robust patient matching and patient identity management. These organizations provide alerts, results delivery, e-prescribing and electronic order entry, query-based exchange, community-wide consolidated records, public health and quality reporting, population health analytics, and other services as required to meet the needs of participants.