Community Information Exchange (CIE)ⁱ networks develop shared governance and technology to support cross-sector collaboration addressing social determinants of health. They bring together diverse partners from health and behavioral health care, social services, education, the legal system, tribal entities, and other organizations to build relationships, goals, and agreements. By delivering core infrastructure and methods for active planning and collaboration across organizations and programs, CIEs serve as critical hubs in communities integrating systems of care to improve services and outcomes, especially for their most vulnerable residents. 

Many related initiatives have advanced integration within systems of care. For example, Health Information Exchange (HIE) efforts aggregate medical data in one record that clinicians across health systems can access, while housing Continuums of Care have come together to build coordinated entry services and shared documentation in homeless management information systems. CIEs, in contrast, knit together these partners through tools and data that span sectors to provide more holistic and actionable views of community needs and the complexity of individuals. My colleague Mark Elson provides more information on the distinctions between HIE and CIE in a companion post. 

There are many types of processes that CIE networks try to improve through shared goals, agreements, and technology. These often include:  

• • Assessments of individuals’ needs 
  • Eligibility and enrollment in appropriate programs and services  
  • Building an individual care record and a holistic care plan 
  • Facilitating referrals for services across organizations and sectors linked to a community resource directory 
  • Communications and workflows among distributed care teams 
  • Individual consent for data sharing and participation in organizing one’s care 
  • Reporting and analytics to illuminate inequities and upstream causes of health and social issues, and to identify gaps in service supply  

Policy Drivers 

Many programs and funding streams across the country are driving cross-sector collaboration. These include Accountable Communities for Health, Medicaid transformation projects, issue-focused funding (such as Adverse Childhood Experiences (ACEs) Aware), and state legislation that all push for collaboration between health care providers and community-based organizations. Each has a slightly different focus, but all are pushing communities to build connections across sectors to improve services, experiences, and outcomes for vulnerable populations. Below we describe a few programs that have allowed innovative communities and CIE pioneers to start building capacity, infrastructure, and sustainable collaborative practices.  

Federal programs: Center for Medicaid Services (CMS) 

Starting in 2015 to advance the triple aim, CMS began funding some states to implement Accountable Communities for Health.  These began as regional public private partnerships that are designed to be conveners, coordinating bodies, and investment hubs to better connect health care delivery systems to community service providers. In 2016, CMS funded additional five-year Accountable Health Community pilots in 28 communities, which focused on connecting eligible residents with community services to address five core health related social needs: housing, food security, utility assistance, transportation problems, and interpersonal violence. Services focus on screening, referral, and navigation, with most screening occurring in hospital settings. The first evaluation report indicated that most communities built upon existing infrastructure and relationships, but that AHC funding allowed for the formalization of processes for screening and referrals, and expanding capacity for navigation services.  California funded 8 regional ACH communities through these State Innovation Model funds. In the years since then, many other California Medicaid innovation projects have continued to drive cross-sector collaboration. 

 In 2016, California matched CMS funding with state general funds and local sources to test new cross-sector collaboration approaches with DHCS’s Whole Person Care pilots. This program funded 25, 5-year pilot programs to develop new wrap-around case management services to better serve clients with complex needs. These funds allowed lead entities,  

to receive support to integrate care for a particularly vulnerable group of Medi-Cal beneficiaries who have been identified as high users of multiple systems and continue to have poor health outcomes. Through collaborative leadership and systematic coordination among public and private entities, WPC Pilot entities will identify target populations, share data between systems, coordinate care real time, and evaluate individual and population progress – all with the goal of providing comprehensive coordinated care for the beneficiary resulting in better health outcomes. 

This program funding continued regional pressure in California to knit together health, behavioral health, and social service systems of care with improved agreements and collaboration processes or tools. Rather than just focusing on referrals from hospitals, many WPC pilots required the development of a shared care plan across organizations providing care within 30 days of enrollment. This pushed many counties towards identifying cross-sector care teams, developing more sophisticated data sharing frameworks, and implementing secure collaboration tools. Some counties built upon assessment and referral infrastructure. Others focused on implementing tools that would allow for more in-depth data sharing for long-term case management and collaboration. 

State Initiatives: 

Two other initiatives continued to push collaboration for specific populations. In 2018 the State passed Senate Bill 1152 (Health and Safety Code § 1262.5) which requires hospitals to have a written plan for coordinating services for patients experiencing homelessness. This bill increased pressures on hospital systems to have an efficient way to refer patients to community-based services and has led many regional efforts to implement directory and referral networks. In 2020 California also announced funding for the Adverse Childhood Experiences (ACEs) Aware initiative. This program provides grant funding to communities across California to build networks and strategies to address Adverse Childhood Experiences and toxic stress. Grants support provider engagement and training, but also building a network for care planning and care implementation, creating new opportunities and new challenges for existing networks and service providers. 

The outcome of many of CMS’s pilot projects is the creation of a new a Medicaid benefit for vulnerable California residents. This year, Whole Person Care pilots are transitioning many services into Medicaid benefits offered by Managed Care Organizations (MCOs) under California Advancing and Innovating Medi-Cal (CalAIM). The program is focusing on building capacity to implement population health management strategies, and offering integrated services to key populations of interest, starting with Medi-Cal members with complex medical needs (Enhanced Care Management) or who are experiencing homelessness or require other community services to support health like medically tailored meals (Community Supports). Future waves of implementation will include better access to behavioral health services and re-entry services for justice involved adults and youth. While important for long-term sustainability of critical case management and community services, transition of the program to MCOs is challenging the systems set up under WPC pilots. 

CIEs as Multi-Purpose Infrastructure 

What all of these examples illustrate is that there are often short-term initiatives that drive innovation; however, each of these efforts has its specific program requirements and target populations. Building a CIE requires stepping back from each individual program’s specific needs, to consider the broader long-term goals of a community. CIE development must start with those broader goals to build a system that centers the experience and rights of community residents, that does not over-burden community-based service providers, and does not continue to build and re-build with every program transition. Braiding together program funding can bring new providers into the network of stakeholders, or could allow the network to serve new groups of residents, but the goals should be to build a resilient, multi-purpose system of care and collaboration that will outlast any one programmatic funding stream. This requires the lead local entities on specific programs to work through a broader community framework, an approach that at times generates resistance from program managers whose jobs require them to deliver on their specific program needs, often on short timelines from state or federal funders.   

One CIE pioneer, the 211/CIE San Diego, has harnessed programmatic funding opportunities over the past two decades to establish and expand their network of service providers, build a community governance framework, and implement multi-purpose technology solutions. CIE San Diego defines CIE as  

“a community-led ecosystem comprised of multidisciplinary network partners using a shared language, a resource database, and integrated technology platforms to deliver enhanced community care planning. A CIE enables communities to have multi-level impacts by shifting away from a reactive approach towards proactive, holistic, person-centered care. At its core, CIE centers the community to support anti-racism and health equity.”  

In a presentation at the California Primary Care Association meeting in 2019 entitled, “Community Information Exchanges (CIE): Changing the Landscape – Coordinating Social Determinants of Health,” they present a timeline that shows how they have harnessed opportunities to grow, test, and iterate their service offerings over time (Slide 9). These have included initiatives like the ONC’s Beacon Community grants that supported HIE expansion after the passage of the HITECH act, partnership and funding from Managed Care Health Plan partners for health navigation services, and California Whole Person Care funding that helped expand structured approaches to assessment, risk ratings, and developing a longitudinal care record in a shared technology platform. They expand upon some of the influences shaping CIE in the opening sections of their CIE Toolkit, which they offer to other communities engaged in this work. 

211/CIE San Diego has produced and shared many practical resources designed to help communities build beyond individual program requirements. 211/CIE San Diego’s CIE toolkit and the Data Equity Framework (Collaboratively developed with Dr. Rhea Boyd and Health Leads) provide tools that center community vision, goals, and control of information and data. They offer both written materials and a series of sessions from the 2021 CIE Summit called “Leading with Community to Drive Systems Change.” In addition to sharing lessons learned on broad CIE implementation they offer many materials to help CIE communities put equity theory into practice through their series on Leveraging CIEs for Equitable and Inclusive Data. This includes the data equity framework, a vision for the future, and examples of CIE work in communities around the country. In 2022, they are focusing their convening efforts on a conference called Aligning California, Maximizing Opportunities to Advance Local Community-Led Networks. The need for this type of convening stems from both the opportunities and challenges communities feel as CalAIM and other pressures push regional networks to adapt to new programmatic demands. 

Conclusion 

CIEs are ideally positioned to power cross-sector collaboration and data sharing to address community needs across programs. Many communities developing CIE services are sharing learnings and tools to build policy and technology frameworks that center on clients, support front-line service providers, build local control of data, and unify systems of care. We will explore how large-scale initiatives such as CalAIM can support broad systems planning and collaboration rather than building new program silos, and how some communities are doing this work, in future posts. 

ⁱ CIE® is a registered trademark of 211 San Diego. For more information about the trademark, see the following webpages on the legal status and brand guidelines for the term.  

Propelled by local and government demand for services coordination across health, behavioral health, housing, and other social services, the concept of Community Information Exchange (CIE)ⁱ is gaining momentum in communities across the country. As explained by my colleague Keira Armstrong here, CIE enables collaboration and data sharing to address social determinants of health through whole person care approaches. 

In this post, I contrast Community Information Exchange (CIE) with Health Information Exchange (HIE) to cast into relief important differences, highlight core similarities, and explore the alignment of HIE and CIE services. A primary goal here is to assist health care colleagues who are familiar with HIE to grasp more concretely the opportunities and challenges of CIE and what they mean for our field. I conclude with considerations for HIOs that wish to expand to offer CIE services and, on the other side of the coin, offer recommendations for CIEs that seek to leverage the value of health information exchange in their communities. 

What’s in a Name? 

It has become standard practice to refer to the act of health information exchange (“the verb”) as HIE (or “data exchange”), while referring to organizations that facilitate and manage HIE as Health Information Organizations (HIOs). In contrast, the term Community Information Exchange (CIE) designates both the act of engaging in CIE and the organizations dedicated to facilitating this activity (CIEs). I will focus here on HIOs and the services they provide rather than on broader national EHR-based networks for data exchange given that CIEs have much more in common with HIOs than with the national networks. 

The name “Community Information Exchange” bears a clear resemblance to “Health Information Exchange,” and “CIE” likely was coined in reference to “HIE.” Whether intentional or not, the name “CIE” gives the impression of describing the same phenomena as HIE, but with a twist: a focus on the community level of exchange and the inclusion of non-clinical data from social and human services. However, as we will see, CIE generally does not simply take the form of HIE and sprinkle in some additional data elements; while they do share important characteristics, there are fundamental differences in orientation, services, and aims. In short, while HIOs facilitate data exchange among health care providers and health plans for a complete historical clinical record, aspects of which can be delivered into clinical workflows, CIEs serve as user-facing collaboration hubs for coordination of services across sectors.   

Many programs, for instance Medicaid delivery system integration efforts such as the 1115 Waivers in California (CalAIM) and New York (DSRIP 2.0), require significant CIE services but do not use the term “CIE” to denote them – reflecting the fact that we are dealing with emerging phenomena without fully settled naming conventions. As this and our companion piece describe, we take a broad view of CIE as the best single lens – to date – through which to understand a range of related activities and infrastructure. 

Similarities and Differences 

The table below compares HIOs and their HIE services with CIEs and their CIE services; this mapping represents core prototypes of each category and may not apply in marginal cases.  

Integrated or Complementary Services? 

Five or so years ago, one might have realistically imagined that HIOs would add CIE services – such as technology for community-level care coordination and closed-loop referrals between health and social services – to their offerings. Medicaid agencies in states like California and New York were pouring billions of dollars into the alignment of the Medicaid delivery system with social and human services to address social determinants of health and complex care needs, and data infrastructure was at a premium for this transition. Nevertheless, HIOs largely stayed in their clinical lane, while a new set of coalitions (CIEs, Whole Person Care Pilots, referrals networks, etc.) and vendors (closed-loop referrals, care coordination) emerged to meet the demand. This conservative approach by HIOs has been driven by the structural differences between their historical business model and the emerging CIE model documented in the table above and further elaborated here: from differences in participants and leadership, to data governance and consent, to distinct services. 

• • Participants and Leadership. HIOs are led by Boards of health care representatives from among their participating organizations, with little if any representation from social or human services; they naturally focus on clinical data exchange and workflows; to the extent that HIEs participate in cross-sector engagement, they typically do so from a health care perspective; 
  • Data Governance and Consent. Getting to “yes” for HIE has not been an easy road for most health care organizations, given legitimate concerns about data privacy and security and the use of data for competitive ends. While that set of debates has largely been settled in favor of data exchange, sharing clinical data with social and human services providers has introduced a new set of challenges. In California, state statutes and regulations specific to Medi-Cal’s Whole Person Care and CalAIM programs established a “safe zone” for cross-sector data sharing relative to state law. Even so, nearly all of these state-funded local efforts have also implemented comprehensive individual consent for data sharing that covers a broad, multi-purpose set of use cases including both HIE and CIE services. In contrast, most HIOs outside of states such as New York, which implemented an “opt-in” consent framework, do not obtain individual consent due to the perceived administrative burden. As a result, these HIOs, which include all HIOs in California, have essentially disqualified themselves from being able to offer CIE services at scale. This situation is unlikely to change unless there is action at the state level to both mandate and manage individual consents for cross-sector data sharing and collaboration.
  • Service model. HIOs are in the business of data collection, aggregation, and access. A baseline form of access is a read-only HIE portal with longitudinal, historical patient records. HIOs also deliver some patient data directly into their participants’ IT systems so that actionable information can be incorporated into providers’ workflows. In contrast, CIEs offer high-touch tools accessible through a user interface for care coordination with write-to and not just read-only functionality, and it is important for users to operate in the CIE platform itself. They do not attempt to provide comprehensive longitudinal records. To address workflow issues for providers who prefer to stay in their EHR, APIs can enable users to access the CIE platform from within their EHR, although such capability has not been broadly implemented. In any case, the provision of a user interface for real-time collaboration is a departure from the HIE service model of providing access to and delivering historical patient data. 

Due to these factors, we have not seen a single HIO in the country offer CIE services at scale – to all of its members and covering all of the population it serves through HIE. Instead, complementary rather than integrated services have emerged at the intersection of HIE and CIE where such innovative connections have been proactively pursued. In many cases, HIOs have acted as data-sharing partners to CIE efforts and their core vendors, pushing actionable clinical information to the CIE. This takes advantage of HIOs’ core service as clinical data suppliers, albeit to a new type of partner. A small number of HIOs in California have gone so far as to contract with care coordination platforms on behalf of County-led Whole Person Care pilots (we supported such developments in Humboldt, San Joaquin, and Santa Cruz Counties). These HIOs implemented focused data sharing between systems such as the delivery of hospital event notifications into the care coordination platform. Some other HIOs outside of California have begun to contract with closed-loop referrals vendors (including state HIE networks in Michigan, Arizona, and Colorado), but it remains to be seen how they will integrate such services with their core HIE offerings. In all of these cases, CIE services have been developed through parallel technical and governance infrastructure to HIE, rather than being integrated into the HIO’s governance and technical infrastructure for HIE. Alameda County’s Whole Person Care Pilot has perhaps gone the furthest, building a new Social Health Information Exchange from the ground up with its vendor partner UpHealth that offers many HIE and CIE type functions; the County is now in the process of exploring full HIO status within California’s structure for data exchange. 

Conclusion 

HIOs and CIEs share a number of important structural features, such as data exchange across organizations to improve services and outcomes, multi-purpose infrastructure, multi-stakeholder governance, and a value proposition driven by the density of participation among organizations serving a shared population. However, they have distinct service models, different participant and Board profiles, and the majority of HIOs that do not obtain patient consent have an additional barrier to merging CIE services with HIE. Given this confluence of factors, CIEs will likely continue to emerge as distinct coalitions and networks in many regions, while some innovative HIOs will contract with CIE vendors to offer specific CIE services for a subset of their members and population, positioning them to explore deeper integration over time. Across the board, given policy and market demand, HIE and CIE services will become increasingly complementary regardless of their organizational homes – while retaining their unique identities and functions.  

Considerations for HIOs that want to expand into CIE. HIOs are well positioned to play a key role in supporting CIE. Below is a list of some ways that HIEs may do so.  

• • If CIE exists in an HIO’s service area, the HIO may offer to serve as a supplier of relevant clinical data to the CIE. This provides a “single pipe” of clinical data to the CIE, saving the CIE tremendous time and effort in establishing inbound clinical data feeds. Data governance of clinical data shared with the CIE would become the responsibility of the CIE to manage, and this should be spelled out in the data sharing agreement between the two organizations.
  • An HIO’s Master Patient Index (MPI) is one of its most valuable assets, and this asset could be used to support identity management within CIE technology tools, which may not have either the same level of patient-matching sophistication or data for identity management.
  • Some communities with multiple vendor networks for social referrals have sought a technology solution to sit in the middle of these networks to direct referrals traffic between them. An HIO could either seek to develop this capability in-house or contract with a third-party vendor to operate such a function locally, potentially leveraging other HIO assets such as the MPI in the process.  This aligns with HIOs’ commitment to interoperability.
  • An HIO may be well positioned to mediate data exchange between different types of CIE tools as well (e.g. a care coordination system and a referrals system), or mediate a CIE’s ingestion of data from other relevant non-clinical data sources (e.g. Housing Management Information Systems, jail scheduling systems).
  • An HIO may be well positioned to receive specified data feeds from a CIE system to then aggregate social and clinical data and enable population analytics.
  • As seen in several examples above, an HIO may manage a procurement process and hold contracts with CIE vendors on behalf of the community.
  • In addition to holding contracts with CIE vendors, an HIO with a strong governance structure that can accommodate new members and voices from social and human services would be well positioned to consider serving as the CIE backbone organization in its community.
  • Conducting an assessment of the HIO’s governance, technology, and business models to evaluate the HIO’s readiness to embrace CIE could help HIO leadership consider how complementary HIE and CIE services could offer stakeholders cost-effective multi-program infrastructure. Understanding state and federal requirements related to consent, and a potential reconsideration of the HIO’s consent model to enable CIE use cases, may yield important insights on both opportunities and challenges ahead.  

Considerations for CIEs that want to leverage HIE. In the other direction, CIEs can leverage HIOs in the following types of ways (many of these correspond to an item in the list above, but from the CIE perspective). 

• • If a CIE effort is early-stage and has not identified a backbone organization, consider the local HIO as part of the selection process for this role. HIOs have years of accumulated experience with multi-stakeholder governance of critical data assets, and may be in an ideal position to expand their scope and leadership structure to serve as the CIE backbone organization.
  • Explore engaging an HIO as a supplier of relevant clinical data to the CIE. This provides a “single pipe” of clinical data to the CIE, saving the CIE tremendous time and effort in establishing inbound clinical data. Data governance issues, such as appropriate user access controls, are the responsibility of the CIE, and should be spelled out in the data sharing agreement between the two organizations.
  • An HIO’s Master Patient Index (MPI) is one of its most valuable assets, and this asset could be used to support identity management within CIE technology tools, which may not have either the same level of patient-matching sophistication or data for identity management. 
  • Some communities with multiple vendor networks for social referrals have sought a technology solution to sit in the middle of these networks to direct referrals traffic between them. If this is an issue in your environment, consider partnering with an HIO that could either seek to develop this capability in-house or could contract with a third-party vendor to operate such a function locally, potentially leveraging other HIO assets such as the MPI in the process. This builds on the HIO commitment to interoperability.
  • If contracting with multiple types of CIE vendors, consider leveraging an HIO to mediate data exchange between them (e.g. a care coordination system and a referrals system);
  • Look to the HIO to mediate your CIE’s ingestion of data from other relevant non-clinical data sources (e.g. Housing Management Information Systems, jail scheduling systems), if the HIO is able to accommodate such data.
  • An HIO may be well positioned to receive specific data feeds from your CIE system(s) to then aggregate social and clinical data and enable population analytics, resulting in cost-sharing for such functionality between the HIO and CIE.
  • Consider partnering with an HIO to serve as the contract-holder with all CIE vendors to centralize vendor management; if the CIE backbone organization is separate from the HIO, it would execute an all-in-one agreement with the HIO for these services;  
  • Conduct an assessment of the CIE’s governance, technology, and business models to evaluate readiness to engage with an HIO, ingest clinical data from the HIO, and effectively align services. If the HIO collects patient consent, evaluate whether the consent form and process can be expanded to support cross-sector collaboration and data-sharing. Consider how HIO and CIE alignment offers stakeholders cost-effective multi-program infrastructure. 

• ⁱ CIE ® is a registered trademark of 211 San Diego. For more information about the trademark, see the following webpages on the legal status and brand guidelines for the term.