HIE may work best if starting small

So the VA EMR can't talk to the DoD's system--no surprise, given the gigantic bureaucracies involved. But it's daunting to consider that this is just one flavor of a nationwide problem we're facing as we fight to establish health information exchanges.

If two extraordinarily-well funded organizations can't link up their systems after nearly 10 years and almost $2 billion in effort, what does that mean for the "little guys" in regional RHIOs?

As we note below, one small Boston-area exchange faces big challenges just in getting patients with EMRs to agree to share information with other doctors. These community organizations don't have the ability to force the matter through legislation, and Lord knows they don't have the DoD's budget, so they're just going to have to wing it.

Ultimately, I'd say that administrative challenges like these, more than development issues, are the most daunting part of the logistics of building an HIE. If the two agencies can't get it together, even when they're in one sense under the same umbrella, imagine the hurdles local agencies have to jump.

Not only do they have to get patients to sign the necessary releases, set up trusted intermediaries everyone can work with and fund ongoing hosting and sharing of the information, they also have to convince everybody that this is in their interest. It's not easy.

On the other hand, if anyone can make it happen, I'd imagine it would be a small organization like the Massachusetts eHealth Collaborative. In this relatively small group--which includes only three towns--the players know each other, and that kind of intimacy is likely to work in their favor.

The more I think about it, the more it seems to me that the HIE may movement may need to emerge from small seeds of this kind. Otherwise, you end up with sprawling quasi-failures like the DoD integration project, and nobody wants that. - Anne