The American Journal of Managed Care November 2011
Health Information Exchange Among US Hospitals
Objectives: To determine the proportion of US hospitals engaged in health information exchange (HIE) with unaffiliated providers and to identify key hospital-level and market-level factors associated with participating in exchange.
Study Design: Using the 2009 American Hospital Association Information Technology survey, supplemented by Dartmouth Atlas, Area Resource File, and other national data, we examined which hospitals participated in regional efforts to electronically exchange clinical data.
Methods: We used logistic regression models to determine hospital-level characteristics and market-level characteristics associated with hospitals’ likelihood of participating in HIE.
Results: We found that 10.7% of US hospitals engaged in HIE with unaffiliated providers. In communities where exchange occurred, for-profit hospitals and those with a small market share were far less likely to engage in HIE than nonprofit hospitals or those with a larger market share. Hospitals in more concentrated markets were more likely to exchange and hospitals in markets with higher Medicare spending were less likely to exchange.
Conclusions: At the start of implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act, only a small minority of US hospitals electronically exchange clinical data with unaffiliated providers. Health information exchange is a key part of reforming the healthcare system, and factors related to competitiveness may be holding some providers back.
(Am J Manag Care. 2011;17(11):761-768)
Health information exchange (HIE), in which clinical data follow patients between delivery settings, is a critical component of reforming the healthcare system.
- Our findings suggest that hospital participation in HIE is low.
- Our work suggests that concerns related to competitiveness are playing a role, with for-profit hospitals and those with smaller market share less likely to participate.
- This low rate of participation is a challenge that will be encountered by federal policy makers as they design future stages of meaningful use incentives, as well as by states as they build out HIE capabilities.
The HITECH Act does not specify how HIE should be achieved, and as a result, an array of options are emerging. They range from the federally initiated Direct Project, a set of standards that allow senders to push health information securely to known receivers, to marketbased HIE solutions that can be used to create an exchange network. Over the past decade, health information organizations (HIOs) have served as the primary mechanism by which the United States pursued clinical data exchange.6 Health information organizations offer a particular approach to achieving HIE by bringing together stakeholders with clinical data (eg, physician practices, laboratories, hospitals) in a given geographic region and setting up the infrastructure for HIE. Since many HIOs are well established and have substantial experience supporting HIE, they appear likely to serve as a foundational approach under HITECH. For examples of HIO-based plans, see Colorado, Indiana, or New York at the State Health Information Exchange Program Web site.7
Health information organizations face challenges on multiple fronts, including a lack of funding, concerns about privacy and security, legal and regulatory challenges, technical challenges, and stakeholder concerns about competitiveness.8 Health information organizations have also had to accommodate providers without EHRs, often by making data available on a portal that can disrupt work flow. The policy response has focused on securing funding—most recently in the form of large grants to states to increase HIE—as well as increasing EHR adoption and setting rules for data privacy, security, and technical standards.2 Providers’ concerns about the competitive implications of HIE, which have been documented in several case studies,9-12 have received far less attention. In case studies, hospitals report that patient data tie both patients and providers to their institution, conferring a competitive advantage that would be lost by participating in an HIO.9,10 Yet we know little about how broadly hospitals are engaged in HIE and whether certain key factors, especially those stemming from competitive concerns, are related to the decision to participate.
Therefore, we used nationally representative data to answer 3 questions. First, what proportion of US hospitals are exchanging clinical data with unaffiliated providers through an HIO (“engaging in HIE”)? Because the data were collected in the months after passage of HITECH, it offers a baseline against which national HIE progress can be measured. We focused on HIE taking place through HIOs because HIOs were the predominant strategy available when our data were collected and they are a key part of many states’ plans for expanding HIE.7 Second, are certain key hospital characteristics associated with the decision to engage in HIE? Specifically, we hypothesized that for-profit hospitals and hospitals with a small market share may be more concerned about loss of market share and therefore may be less likely to engage in HIE. Teaching hospitals, which routinely serve as referral hospitals, may be more likely to engage in HIE. Third, do features of healthcare markets where hospitals function affect the hospitals’ likelihood of engaging in HIE? Specifically, we postulated that hospitals in more concentrated markets or those with less fragmentation of hospital care would be more likely to engage in HIE.
We used national data from the IT supplement to the annual American Hospital Association (AHA) survey, which was administered during the spring and summer of 2009 to all acute-care hospitals, more than 95% of which were AHA member hospitals. 13 A total of 3725 member hospitals responded to the IT supplement survey (a response rate of 69%), and we limited our analytic sample to the 3101 acutecare, nonfederal hospitals located in the 50 states and the District of Columbia. We defined a marketas a hospital referral region (HRR), a designation developed by the Dartmouth Atlas to define healthcare delivery markets based on Medicare beneficiary travel patterns for tertiary hospital care.14
The AHA IT supplement included 2 questions related to HIE: (1) whether the hospital participates in a regional HIO (or a regional HIO-like effort) to share electronic patient-level clinical data and (2) whether the hospital electronically exchanges each of 5 types of data (eg, laboratory reports, clinical care records) with hospitals or ambulatory providers that are part of a different system. (Original survey questions are included in eAppendix 1, available at www.ajmc.com.) We merged the IT supplement data with results from the annual AHA survey to develop measures at the market level as well as capture additional hospital characteristics. The Area Resource File, Medicare Provider and Analysis Review File, and Dartmouth Atlas were used for additional market level measures.
Outcome Measures. We determined that a hospital engaged in HIE based on how it responded to the 2 HIE-related questions. Hospitals that (1) reported participating and actively exchanging data through a regional HIO (question 1) and (2) reported that they exchanged at least 1 type of clinical data with either hospitals or ambulatory providers that were part of a different system (question 2) were classified as participating in an HIO. Our approach helped ensure that the definition of HIO participation was consistent with the commonly held criteria that (1) HIE is actively occurring, (2) clinical data are exchanged, and (3) exchange takes place between organizations that are not part of the same system, which will be required under meaningful use.3,8 Given that most HIOs are relatively new,5 we did not require robust exchange (ie, multiple types of clinical data), though this is ultimately what is likely required to realize meaningful efficiency gains from HIE. We identified markets with HIO presence as those in which at least 1 hospital in the HRR was classified as participating. We sought to validate hospitals’ responses about participating in an HIO and exchanging data by examining a recently completed national survey of HIOs.5 In this survey, HIOs were asked to identify the hospital service area(s) in which they functioned and actively facilitated clinical data exchange. We compared these areas with the areas in which hospitals reported participating in an HIO on the AHA IT supplement. We found substantial overlap, giving us confidence in the validity of hospitals’ responses about HIO participation.
Hospital Characteristics. We examined 8 hospital characteristics, 3 of which were chosen a priori based on our hypotheses about which hospitals might or might not participate in an HIO: ownership (for profit, nonprofit private, or public), bed share in the market, and teaching status. The remaining characteristics were those that we thought might be directly related to participating or might confound the relationship between the 3 primary variables of interest (ownership, bed share, and teaching status) and participation: size, proportion of Medicaid admissions, whether the hospital was affiliated with a system, and whether the hospital had significant technological capability (a coronary care unit) and IT resources (an EHR).
Market Characteristics. We also examined a series of market-level characteristics. We created 2 measures to capture the competitiveness of the market. We measured market concentration using the Herfindahl-Hirschman Index. We measured market fragmentation as the proportion of discharged patients subsequently readmitted to a nonaffiliated hospital within the same market. Additional market-level measures included mean annual Medicare inpatient expenditures, mean proportion of hospitalizations from Medicare patients, urban/rural location, geographic region, managed care penetration, population density, percentage of the population that was uninsured, and per capita income. Each of these variables was chosen because we believed that it might be directly related to promoting HIE or might confound the relationship between the market variables of interest (market concentration and market fragmentation) and HIE. More details on why each measure was chosen and how it was defined are available in eAppendix 1.
Analysis. We first calculated an adjusted overall participation rate among all respondents in our sample. We used weights to adjust for potential nonresponse bias after finding modest but significant differences when comparing respondents and nonrespondents to the survey (eAppendix 2, available at www.ajmc.com). We next examined whether our hypothesized hospital characteristics were related to a hospital’s decision to participate in an HIO. We started with bivariate relationships and then built multivariable logistic regression models with hospital-level sampling weights and robust standard errors adjusted for clustering at the market level. Our analyses compared hospitals that participated in HIOs with those that did not within HRRs that had an HIO. Looking within the 165 HRRs (54%) with an HIO helped to ensure that hospitals had an opportunity to participate. We next examined whether our hypothesized market characteristics were related to hospital participation by adding marketlevel measures to the multivariable logistic regression model.