The Interplay of Top-Down and Bottom-Up: Approaches for Achieving Sustainable Health Information Exchange

The exchange of patient health information across different organizations involved in healthcare delivery has potential benefits for a wide range of stakeholders. However, many governments in Europe and in the U.S. have, despite both top-down and bottom-up initiatives, experienced major barriers in achieving sustainable models for implementing health information exchange (HIE) throughout their healthcare systems. In the case of the U.S., three years after stimulus funding allocated as part of the 2009 HITECH Act, the extent to which government funding will be needed to sustain health information organizations (HIOs) that facilitate HIE across regional stakeholders remains an unanswered question. This research investigates the impacts of top-down and bottom-up initiatives on the evolutionary paths of HIOs in two contingent states in the U.S. (New Jersey and New York) which had different starting positions before the HITECH funding. Based on our analyses of interview data collected from 34 leaders at the state, HIO, and provider level, our objective is to develop a model of contextual and operational factors that influence the sustainability of HIOs. The implications of our findings for other networks of heterogeneous healthcare systems, such as in the European landscape, will also be explored.