• Each region or sub-network needs an entity (Sub-network Organization) to oversee its health information environment. Regional sub-networks have a public interest responsibility to address the needs of the entire population and all health information providers. Some sub-networks will be geographically based and others will be functional or organizational, crossing geographical boundaries. Some of these enterprise or private sub-networks (e.g., a large health system or research network) may not be subject to the same public interest governance and policy obligations. The responsibilities of the Sub-Network Organizations include:
  1. Establishing a multi-stakeholder governance structure that includes the representation of patients and consumers and safety net providers. The governance structure should be formalized and address the corporate and tax status of the Sub-Network Organization, its business plan and budget, intellectual property ownership and management, the entityıs statement of purpose and objectives, its decision making model, and its long-term strategic plan. Various types of governance model are acceptable.
  2. Defining and meeting the particular information access needs of the region or sub-network while addressing the needs of patient populations that cross multiple communities nationwide or are contiguous but cross state lines.
  3. Organizing the creation of "Articles of Federation" and other user agreements. A common set of multi-lateral policies, procedures, and standards to facilitate reliable, efficient sharing of health data among authorized users is required. The participating members of the health network must belong to and comply with agreements of a federation. Formal federation with clear agreements allows participants to access information that they have been authorized to share.
  4. Supervising uniform adoption of information sharing policies or Articles of Federation by participating entities and mechanisms for their enforcement (e.g. sanctions).
  5. Developing policies to address the need for retention and persistence of data.
  6. Addressing conflicts among relevant stakeholders in a timely way.
  7. Building, maintaining and managing the regional Record Locator Services and other sub-network systems and services.
  8. Assuring that sub-network systems and the end-point systems of their members (including the Record Locator Service) adhere to the Common Framework.
  9. Providing support to participants in the federation.
  10. Establishing the financial sustainability models for the entity‹responsibilities include:
      1. Working with community payers, purchasers and providers to discuss participation, incentives and appropriate funding models.
      2. Monitoring relevant stakeholder participation regarding conformance with the Common Framework and adoption incentives.
  11. Ensuring that all of the information capabilities that define the Health Information Environment (including public health reporting and surveillance, research and improving health care quality) can be met over time.

In regions where there is low potential for an organizing function, (e.g., rural and underserved), other models of non-geographic sub-networks and Sub-Network Organizations should be established to support these necessary sub-networks. For example, there may be cases, especially in rural areas, where specialized clinical data repositories, or proxies, are shared by the providers in the community. Rural networks that may be meeting the needs of relatively closed provider networks may be best served by shared clinical data repositories that allow acceptable access speeds even when broadband Internet access is limited or less efficient. Any model must include the possibility for such clinical data repositories or proxies to exist as long as they comply with the Common Framework for interacting with other sub-networks as appropriate for patient care or other authorized use. Alternatively, some Sub-Network Organizations can explore potential partnerships with the appropriate State Health Departments, Medial Societies, NGOs, etc.