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information exchange. There are many similarities and many differences.
In some states, the state-level HIE governance organization was created
by statute before ARRA and became the state-designated entity. In other
states, the state-designated entity was created by executive order, while in
others, by appointment of the governor. In all cases, a primary role of the
state-designated entity is to manage the HIE Cooperative Agreement with
the ONC (Covich et al., 2011).
The locus of control for the HIE governance organization differs by state
as well. In some states, the HIE governance organization is controlled by the
state government through a state agency that directly oversees the develop-
ment of the state-level HIE or manages another technical or administra-
tive organization that takes responsibility for the HIE. In other states, the
HIE governing organization is an independent, not-for-profit organiza-
tion that takes on the responsibility of developing the state-level HIE for
the state-designated entity. The form of governance structures thus adapts
to the unique requirements of each state, though many states are moving
from the state-driven direct governance to a not-for-profit governing body.
In each case, the HIE governance organization plays a unique and valu-
able role as the mediator between state interests and the private healthcare
sector. It “serves as a neutral and skilled resource for convening diverse
statewide stakeholders and leading and coordinating consensus-based
efforts to develop and implement a statewide road map for interoperability”
(Dierker, 2008). To succeed in this role, the HIE governing organization
has to address and facilitate agreement on numerous issues surrounding
the exchange of medical records both for public health and for private pro-
viders. It has to represent the interests of both the state government and
private enterprise. Finally, the HIE governing organization has to become
the vehicle by which competing public and private interests are coordi-
nated and combined.
Determinants of Value for Governance
of Health Information Exchange
The Markle Foundation (New York City), as part of its Connecting for
Health initiative, argues that governance is dynamic, embodying a num-
ber of decision-making and policy-making stages, and that each stage
may have different participants of institution engaged in the process.
Markle proposes three main value components of governance for health
information sharing: (1) clear goals and objectives; (2) processes for the
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