HIE Landscape

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HIE in California

Long before the health information technology boom, California had a community- and enterprise-oriented, decentralized approach to health information sharing. This approach continued during the HITECH era, with the development of the CTEN, a trust framework designed to provide the most flexibility to adapt to California’s complex healthcare ecosystem and emphasize local autonomy to create and operate services that best meet the needs of local users, all 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.

HIE Organizations

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

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

Like enterprises, community HIOs establish the policies for data sharing, as well as the access to the technology and services that moves data. More importantly perhaps, community HIOs also convene a diverse set of stakeholders to solve data sharing problems, and establish collaboration and trust among them.


There are more than 15 community HIEs, with an operational presence in 39 of 58 counties statewide.


Community HIOs receive more than 20 million ATD messages every month, representing data from more than 20 million patient encounters statewide.

Community HIOs have more than 22 million entries in their MPIs, or greater than 56% of California’s total population.


HIOs serve more than hospitals. Most have participants in primary care, local public health, various specialties, and ancillary services.

More than half also serve payers, as well as providers in emergency medical services, home health services and long term care, and mental health specialties. Some include services for substance use disorder providers.


Community HIOs offer a variety of exchange services to their customers. Direct messaging, community-wide longitudinal records, and alerts are common.

More than half of HIOs exchange text reports to fulfill needs not met by structured documents alone. Many support public health reporting and offer a personal health record (PHR) or patient portal to access the community record. An increasing number of HIOs offer services to support quality measures.

Support for order entry and e-prescribing is less common, as these services are often provided by EHRs directly.

Data Types

Community HIOs exchange a wide variety of health information data types. Information contained in care summaries are common: allergies, medications, and immunizations. So are lab results and alerts, including ADT messages.

The majority of HIOs also support text reports and radiology reports, as well as care plans.

HIOs that include payers as participants may also support claims, eligibility determination, and allow reporting of filled medications in addition to those prescribed.

Statewide and Nationwide Exchange

Within the state, the California Trusted Exchange Network (CTEN) provides a simple but robust framework for HIOs to share information with each other. The CTEN combines a multiparty data sharing agreement, a common set of policies and procedures, and a lightweight technical infrastructure to create a trusted environment for safe and secure sharing of health information. California state agencies use the CTEN to access and share health information.

Many HIOs also participate in national information sharing initiatives and frameworks, including DirectTrust accreditation, the Sequoia Project’s eHealth Exchange and Carequality, CommonWell Health Alliance, and Civitas Networks for Health Patient Centered Data Home. A high-level comparison of these initiatives can be found here.