Health Information Exchange in Developing Countries: A Primer

Executive Summary

Health Information Exchange (HIE) is essential in the timely flow of information throughout organizations. Challenges arise when applying HIE techniques in developing countries, especially in areas that do not have access to central servers. Strategies include:

  • Create online discussion groups in areas that do not have access to central servers
  • Implement mobile healthcare delivery
  • Support queries of unassembled information from multiple providers
  • Moving from a paper-based system to a completely electronic mode of health information exchange

Companion Article

A Guide to Planning a Health Information Exchange (HIE)


What is Health Information Exchange (HIE)?

Health information exchange (HIE) is the act of transferring health information electronically between two or more entities. It refers to the real-time or near real-time exchange of information that is essential for the optimization of healthcare systems, especially clinical care, case management and public health.

HIE is not restricted to the flow of information within a single organization. It is distinct from moving information exclusively for billing and other administrative functions, known as electronic data interchange (EDI).  It is also distinct from the transferring of historical data for research and statistical purposes. However, HIE services may also be used for these purposes.

Push vs. Pull HIEs

HIE requires the capability to "push" a message securely from one party to another. This is a post office-like function, sending a message or document - such as a laboratory result or an e-prescription from one organization to another.  This is also referred to as "direct," "point-to-point" or "transactional" exchange.

A second, more sophisticated level of exchange builds on messaging, but also enables users to discover, assemble and "pull" information about one or more patients from various providers. "Pulling" can be used to assemble a longitudinal and comprehensive view of a patient's health history, sometimes called "query," "aggregate" or "community health record" exchange.

Moving from a paper-based system to a completely electronic mode of health information exchange has the potential to transform the healthcare experience for both patients and practitioners. The ability to securely share real-time health information electronically allows healthcare providers to coordinate care, avoid the repetition of medical tests and access more complete medical histories of their patients. (See how HIE can make a positive impact).

HIE Capabilities

Several capabilities are needed for one organization to send private health information securely and confidentially to another. Here is a list of requirements:

  • The sender must assure the recipient's authority to see information (authorization) and confirm their identity (authentication). These are jointly referred to as “identity management”.
  • The information must be delivered to the appropriate address.
  • Patient consent may be needed, particularly when dealing with highly sensitive information.
    Under Canadian privacy law, any information that is related to the provision/delivery of healthcare is considered personal health information, and all personal health information is considered sensitive. This may differ by jurisdiction.
  • There must be a system for the sender to encrypt information, allowing only the intended recipient to decrypt it.
  • The sender must format the information so that the recipient's system can interpret it.
  • If the recipient intends to automate the management of incoming information, semantic interoperability is essential.
  • Both sender and receiver must use compatible data elements and vocabularies or machine-readable code standards, such as ICD-10, LOINC or SNOMED. HL7 version 3 is the messaging standard that enables semantic interoperability. For further information see: "A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure" and eHealth Ontario's Standards Selection Guide.
  • Continuity of Care Document (CCD): an electronic document exchange standard for sharing patient summary information, used for compiling a record for continuity of care purposes.
  • There must be agreement about the ways the recipient may use the information.
  • There must be trust between sender and recipient, often summarized in legal agreements (such as Business Associate or Data Use agreements) that spell out expectations and consequences for their violation.
  • When such trust must extend to many different roles using information in different ways, a fabric of trust or trust framework is needed in order to successfully address these needs while protecting privacy and security.


HIE Technologies

HIE capabilities can be realized with a number of technologies:

  • Secure Internet technology to deliver encrypted information only to authorized users, who are listed in a directory;
  • Portals for data viewing by various users (providers, health departments, patients);
  • To assemble and provide information about a patient from multiple providers, a Master Person Index (eMPI) is required to accurately match and link records;
  • A shared Normalization service, sometimes referred to as “integration capability”, to convert information to the standardized machine-readable formats and vocabularies that enable semantic inter-operability.


To query and assemble a patient record from multiple provider record systems, the following additional requirements must also be met:

  • A way to find which providers hold records about which patient (record locator service);
  • A way to access information stored in others' information systems without threatening the integrity or security of their data.


Some health information exchange organizations (HIOs) focus exclusively on "push" messaging, and do not support queries of unassembled information from multiple providers. HIOs offering "pull" query exchange have different technical architectures related to accessing data, each with different advantages.

These may include centralized, decentralized or hybrid architectures:

  • In a centralized HIE, there is a central or master database which holds a complete copy of all the records of every patient contained in the HIE.
  • In a federated HIE, there is no master database with a previously compiled comprehensive patient record. Each healthcare provider is responsible for maintaining the records of their individual patients. The main function of the HIE is to facilitate HIE members with exchanging patient records as the need arises.
  • A hybrid HIE contains elements of both, with a central database containing some previously compiled patient information and a record locator to other federated data held by HIE members and available as the need arises.

For more information on various HIE architectures see: 2009HIETechnicalModels

These considerations are essential in developing countries, where it can be a challenge to find a cost-effective way to collect data in real-time onto a digital platform, in areas that do not have access to central servers. This challenge has resulted in the emergence of online discussion groups. This problem may be solved by organizations that can facilitate the secure exchange of medical information via mobile solutions.

Mobile healthcare delivery is the new paradigm in developing countries, making the system more affordable, effective and accessible, particularly in rural areas – but there are barriers to overcome. 

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