There are two major types of usage fees that community and state-run HIEs are utilizing: subscription and transaction fees.

Subscription
Subscription fees can be charged to the data providers and users of an HIE.  The subscription fees are a set amount that can be monthly, annual, or by type of service.  The fees will typically vary by the size of an organization or be a tiered structure based on the number of services used.  Subscription fees allow data providers and users to purchase a set level of access. 

Subscription fee based models are often based on a monthly or annual set fee.  This allows HIEs to lower the overall cost of participation, and therefore assist them with long-term planning.  HIEs will need to develop a model to accurately predict usage, in order to assist with long-term planning.  HIEs, in turn, will have more data providers and users participating in the HIE, thereby increasing revenue.  The subscription model also does not disincentivize increased use of the HIE.  In addition, the HIEs administrative costs will be lower, since they will not have to monitor and track individual transactions of any organization.

Transaction
Transaction or “by the drink” fee structures charge data providers and users for each transaction which occurs in the exchange.  Transaction fee arrangements can include fees for sending and/or receiving secure
messages, lab results, claims, eligibility transactions, and others.

There are a number of challenges in the transaction fee structure.  The fees paid to the HIE are not always predictable, they vary based on usage.  For large organizations, transactions can run into the millions/day, causing a potentially unreasonable expense for data providers and users. This may adversely affect usage of the HIE.  Transaction fees are a fluctuating revenue source for HIEs; one month may yield a high number of transactions and therefore revenue, while the next month yields very little. 

A critical factor in sustainability is a steady revenue stream. The transaction fee structure may not provide HIEs the needed stability.  HIEs also must consider the high administrative overhead needed to monitor and record all transactions and assess fees.  This will diminish the revenue generated from the transaction fees.  A benefit of the transaction fee structure is the potential for large revenue, if the participation hurdle can be overcome.  However, it is not yet clear whether organizations will participate en mass in an HIE with a transaction fee structure.  Some HIEs have used a hybrid model that utilizes subscription fees for core services and transaction fees for value-add services.  Examples include HealthBridge, Community Health Information Collaborative, and the Utah Health Information Network.