As accountable care and bundled payments enter the battle for health care dollars, the need to know about all patient care episodes and chronic conditions will prompt providers of all stripes into an information give-and-take they may not have yielded to a few years ago. The motivating force at work, to adapt a Cold War term, is mutually assured data.

Competitors seeking to use HIE to lock up physicians and defend sources of admissions and revenue could end up harming themselves, observers say. Gradually stiffer meaningful use requirements for information sharing, combined with payment plans emphasizing patient health status, will work against provider organizations "becoming walled gardens of information," says Claudia Williams, senior adviser with the Office of the National Coordinator for Health Information Technology.

"If I'm responsible for the quality and outcomes of my patient, if they're admitted to an ER at a different hospital, I have a lot of incentives to want to be sure that the hospital is sharing that basic information with me," Williams says. "Likewise, there'll be a reciprocity [via HIE] to see that everyone benefits."

That means "less of a competitive advantage to the actual information," says Russell Branzell, CIO of Poudre Valley Health System, Fort Collins, Colo. The edge will come from "how we present it, how we give those tools to the physicians—or our caregivers, nurses and others—to make their jobs as efficient as possible, and find the places where we can drive out cost and inefficiency in our system. I think the really smart CEOs see that advantage."

Therein lies the value of HIE, says Dev Culver, executive director of Maine's statewide HIE network. "If the ACO concept really does take root, and if it's a community-based ACO strategy and not a channel-based organization where they're trying to squeeze a patient into a single delivery system, then the health exchange becomes actually fundamental—because it's the only point in the process where you get a common field of information."

But you don't get a common field of information without the full participation of providers in a service area. The aim in northern Colorado, says Branzell, is to connect rural care environments into smaller urban hubs, and those hubs into the large urban hub of Denver. "It requires the aggregate whole; if just a few participate, then that really isn't an exchange."

As physicians are faced with orienting income prospects around individual patient health and managing chronic conditions, astute organizations will see to it that the HIE network they form or join will facilitate communitywide access to information, says William Bernstein, partner with Manatt Health Solutions.

"You're going to be looking to make this simple and [have doctors] deal with one organization," Bernstein says. "It may be that one organization connects with others, but for the basic exchange, you're going to try to have enough value for probably 85 to 90 percent of the places where you send information back and forth, and try to do it with one-stop shopping."

If a health system decides not to play with competitors, it will have to contend with complaints that, among other things, the data from other providers that physicians need for insurance and other reasons will have to be faxed and scanned in to complete the electronic picture, says Douglas Dietzman, executive director of Michigan Health Connect.

And trying to get affiliated but not employed physicians to use a limited health information exchange network will backfire, Dietzman says. "If you go to a physician who's a splitter, why does he want to use your system as part of your affiliate program if the only data in there electronically is your own?" That physician is likely to counter that "if you're going to meet my needs and be a service provider for me, I need all my data electronically. So pretty quickly the notion of, 'I'm going to create my world and just be able to control everything inside my box,' breaks down at some point."