In January 2007, New Haven, Conn. received a $3 million grant from the Center for Community Health Leadership to help the city create a community-wide health information exchange (HIE) to support the exchange of data with community physicians.

Saint Raphael Health System, which championed the grant application, is hosting the technology that will facilitate data sharing across the exchange. Ultimately, the network will touch 22 counties and approximately 800,000 patients in the greater New Haven area. Saint Raphael will serve as the cornerstone of the initiative, establishing a community pilot for a larger, statewide effort that is already underway via eHealth Connecticut.

From the beginning, it was clear that long-term success would depend upon the initiative’s ability to overcome several key challenges, most dominantly a low adoption of electronic health records (EHRs) among the physician groups that are expected to participate in the HIE. The majority of the state’s physicians groups are small and independent; none of the approximately 30-40 small practices impacted by the HIE had EHRs before the beginning of the project, and less than 10 percent of healthcare delivery organizations in the New Haven region have true electronic medical records systems.

The work done by Saint Raphael Health System and its partners leading up to the successful grant application, in particular identifying existing and prospective resources to strengthen the reach and effectiveness of the area’s commitment to health information exchange, is an excellent demonstration of the best practice recommendations conveyed in previous chapters of the “Best Practices Guide to Community Health Information Exchange.”

Assessing the Environment

New Haven’s initiative began by assessing the environment that accounts for political, social and economic interests within the community the data sharing initiative will serve. The goal of this exercise was to both gain a comprehensive understanding of the stakeholder, participant and community resources that can be available to the HIE and to understand the community’s topography to ensure that those resources could be leveraged to the benefit of all stakeholders.

Conducting an assessment to better-understand the environment is important to establishing the community links necessary to move the initiative forward. An environmental assessment also allows identification of the most effective incentives for winning over opponents and keeping stakeholders involved and active.

This is critical because fighting or ignoring the political, social and economic pressures and priorities that characterize the community environment is very likely to result in a failure to fully leverage available resources to the long-term detriment of the initiative.

When properly conducted, the environmental assessment will lead to the accommodation of stakeholder concerns and values, which is key to aligning and maximizing existing and prospective resources, strengthening consensus and finding the focus necessary to move the message from “do you want to do this” to “it’s clear you need to get on-board.”

In a nutshell, environmental scanning assesses the internal strengths and weaknesses of an organization in relation to the external opportunities and threats it faces. For an HIE, typical focal points for the scan are competition, technology, regulatory activity and the economy.

The general steps for conducting an environmental scan are:

  • Identify the purpose, participants and time commitments
  • Carry out the scanning activities
  • Analyze and interpret the strategic importance of issues and trends
  • Select issues and trends for further action
  • Report and disseminate the results

In New Haven, securing the participation of key stakeholders in the community such as Yale-New Haven Hospital (YNHH), Fair Haven Community Health Center and Hill Health Center within the health information exchange is an excellent example of the importance of continuous environmental scanning to an initiative’s ability to fully understand the strengths and needs of the community’s key players, thus making it possible to focus on the most important battles first.

Due to the competitive relationship between Saint Raphael and Yale-New Haven Hospital, participation by the latter was not something the initiative’s leadership expected to happen. However, as the interest of other HIE stakeholders began to strengthen Saint Raphael was asked a lot about YNHH’s participation as was YNHH asked about their interest and participation in the HIE and suddenly the community collaboration and sharing opportunity expanded.

Working together and sharing among competitors is difficult but possible especially if one is listening and looking for opportunities to open discussions and engage in collaboration. Because ongoing environmental scanning was a HIE priority, the initiative leadership quickly became aware of other key stakeholder’s unexpected interest and was able to work with these organizations to overcome the barriers. This was accomplished in large part through the establishment of a neutral foundation that removes proprietary interests so that the main focus can be on improving relations between the regional competitors. This, in turn, encourages their ongoing support of and participation in the initiative.

Targeted Value Creation

Another important strategy in New Haven was to maximize its available resources and follow up the environmental assessment with targeted value creation designed to broaden its pool of participants-a process that will continue throughout the life of the initiative.

During the assessment one of the lessons learned was that maintaining the engagement and participation of provider stakeholders would require that the initiative find ways to create immediate value. Because physicians are a population not always known for their patience, it was important to show value from day one, which for New Haven meant starting on the hospital side with the electronic exchange of lab results.

At the same time, however, project leaders were aware that the focus could not be so narrow as to slow momentum in other areas the initiative had established as priorities with physicians and other provider stakeholders.

As noted in the results from a roundtable discussion convened by the National Institute for Health Care Management Foundation: “The tension between creating short-term and long-term value through HIE is another dimension to stakeholder value clash. RHIO functions that provide short-term return on investment (ROI) through administrative data exchange and improved results delivery may be of greater value to some stakeholders than long-term quality improvement through enhanced outcomes, patient safety, and even expanded access to care. Balancing this tension among different stakeholders to ultimately benefit all stakeholders is key to broad stakeholder participation.”

For example, regardless of the speed and volume at which lab results are exchanged, if physician participants use the local patient clinical information look-up tool in the beginning phases and are unable to find patient records several times in a row, they will fail to see the value of continuing their participation in the HIE. Focusing only on long-term goals and not building incremental value in the minds of the stakeholders will weaken the initiative’s ability to achieve its objectives of connecting the entire provider community.

The solution for New Haven was to handle the organizational efforts in a way that balanced the interests of all the subsets of the provider stakeholder group. At the same time, it was important to establish stakeholder values that allow for future growth. The key here was to align incentives in a way that ensured broad acceptance and long-term support.

New Haven also continues to review its community values to address current and future shifts in stakeholder priorities. This is critical, because community values do not always mesh with stakeholder values, in particular as they pertain to the HIE’s ability to generate revenues.

Health plans and employers are often hesitant to invest in clinical information exchange projects in any significant capacity without seeing reductions in waste through the elimination of duplicative therapies or testing. Further, even purchaser-driven initiatives have struggled to engage providers without the ability to show how the HIE will enhance the practice at the point of care through improved access to hospital and imaging data and administrative savings. Notes Bruce Bradley, director of healthcare strategy and public policy at General Motors: “We struggle a lot with the value proposition because we’re often asked to make investments in our communities, particularly in this area. A way to think about it that resonates with purchasers, in particular manufacturing-type purchasers, is the whole concept of waste. What can [HIEs] do about waste?”

Tapping into Best Practices

New Haven has made a concerted effort to take advantage of the experiences of other communities that have gone through the process of establishing a working health information exchange initiative. The best practices that have emerged from these previous efforts will continue to be an essential external resource as the initiative continues moving forward toward its objectives.

Lessons learned from other sites have provided New Haven with a set of guidelines for navigating issues and for developing viable alternative solutions when roadblocks have been raised. Among the external resources the initiative’s leadership has tapped include sessions on HIE and regional health information organization (RHIO) development and management at key trade conferences such as the Healthcare Information and Management Systems Society (HIMSS), as well as other communities that utilize the same software applications as New Haven and other vendor application user groups.

These conversations are invaluable for the ideas and solutions they generate, as long as they pass the “pressure test” with the initiative’s knowledge of the community it is designed to serve.

Another strategy developed based on these best practices, one New Haven found to be particularly advantageous, is to bring in a neutral facilitator with a deep understanding of the national HIE landscape and expertise gained from working with other initiatives to help keep the process moving forward. Dialogues with other communities made it clear that New Haven needed someone that did not have a stake in the community and with no “skin in the game” to step in when progress stalled and to diffuse potentially disruptive situations quickly and effectively.

Early on New Haven worked with SMC Partners, LLC, a consulting company who has been working with the e-health Connecticut’s board to drive the adoption of HIE’s across Connecticut, to bring impartiality to the collaboration discussions. This proved to be a valuable relationship in the early stages as it provided insight into what other connected communities were doing.

Staying Alert to Opportunities

Long-term success for New Haven will come from its leadership’s ability to utilize the resources at hand, and a commitment to continue assessing the environment to identify and capitalize on opportunities and resources that present themselves in the future.

These may come from inside the initiative, from within the community, or from outside organizations or stakeholders that perhaps were not present in the early days of New Haven’s formation. The key is to be aware of any changes in the political, social and economic environment of the community and to seek ways to continuously expand and strengthen stakeholder participation and value.

Best Practices Guide

The Center for Community Health LeadershipTM, an organization sponsored by Misys Healthcare Systems to facilitate the development of health information pathways by building connected communities, created a thought leadership series focused on encouraging collaboration and providing the guidance necessary to build successful, sustainable community HIE. 

To help community health professionals make HIE a reality, the Center developed guidelines for the creation of a community-based data exchange. Each success factor represents a pivotal point on the path to achieving community-wide information exchange. The Best Practices for Community Health Information Exchange presents success factors, offering prescriptive guidance to carry communities and all represented parties (hospital-based physicians and caregivers, community clinicians, home health organizations and most importantly, community residents) along that path.

To download a free full-version of The Best Practices for Community Health Information Exchange, visit

By: Gary Davidson
CIO of the Hospital of Saint Raphael


Works Cited

Abels, Eileen. “Why Is Environmental Scanning Important?” Bulletin of the American Society for Information Science and Technology. Feb/March 2002. Vol. 28, No. 3.

Available at


Enrado, Patty. “New Haven Lands Grant to Link Healthcare Data.” Healthcare IT News. February 1, 2007.

Available at


Malepati, Sarath; Kushner, Kathryn; Lee, Jason S.. “RHIOs and the Value Proposition: Value Is in the Eye of the Beholder.” Journal of AHIMA 78, no.3 (March 2007): 24-29. Available online at: