US Hospital Engagement in Core Domains of Interoperability

A national assessment of hospital engagement in key domains of interoperability, characteristics associated with engagement in interoperability, and the relationship between interoperability and provider access to clinical data.
Published Online: December 08, 2016
A. Jay Holmgren, BA; Vaishali Patel, PhD; Dustin Charles, MPH; and Julia Adler-Milstein, PhD

Objectives: To assess US hospital engagement in the 4 core domains of interoperability (find, send, receive, integrate) and whether engaging in these domains is associated with electronic availability of clinical data from outside providers.

Study Design: Retrospective analysis of survey data.

Methods: Analysis of the American Hospital Association (AHA) Annual Survey of Hospitals and the American Hospital Association (AHA) Annual Survey of Hospitals - IT Supplement datasets for 2014. Respondents included 3307 US hospitals to the AHA Annual Survey – IT Supplement. We created measures of hospital engagement in 4 core domains of interoperability, as well as access to electronic clinical data from outside providers. Regression analysis was to identify hospital characteristics associated with each measure.

Results: Twenty-one percent of US hospitals engaged in all 4 interoperability domains, and 25% engaged in none. Hospitals engaged in all 4 domains were more likely to have a “basic” (odds ratio [OR], 3.53; P <.01) or “comprehensive” (OR, 5.04; P <.01) electronic health record (EHR) in comparison to a less than “basic” EHR, participate in a Regional Health Information Organization (OR, 4.29; P <.01), use a single EHR vendor (OR, 2.15; P <.01), and have a third-party health information exchange vendor (OR, 2.32; P <.01). They also differed by non-IT characteristics, such as medical home participation (OR, 1.77; P <.01). Hospitals that find (OR, 5.51; P <.01), receive (OR, 2.56; P <.01), or integrate (OR, 2.53; P <.01) information were more likely to report routine clinical information availability from outside providers.

Conclusions: The one-fifth of US hospitals engaged in key domains of interoperability were more likely to have certain information technology infrastructure and participate in delivery reform. Encouragingly, interoperability engagement was associated with routine clinical information availability. Our results point to the need for ongoing efforts to expand interoperability, with the potential benefit of better information availability for clinicians and better care.

Am J Manag Care. 2016;22(12):e395-e402
The Office of the National Coordinator for Health Information Technology (IT) has defined 4 domains of interoperability: find, send, receive, and integrate patient health information from outside sources. We evaluated the current state of US hospitals’ engagement in interoperability:
  • Only 21% of all US hospitals engage in all 4 domains of interoperability.
  • Health IT infrastructure, such as robust electronic health record systems and health information organization participation, and delivery reform engagement are positively associated with engagement in all 4 domains.
  • Three of the 4 domains—finding, receiving, and integrating—are significantly associated with provider access to patient information from outside providers.
  • Hospitals that have invested in interoperability capabilities appear to have better access to patient information. However, given that less than 1 in 4 hospitals have these capabilities, additional policy interventions to encourage interoperability are needed.
Following the large increase in electronic health record (EHR) adoption in US hospitals over the past 6 years,1 attention is increasingly focused on ensuring that EHRs can exchange and integrate patient data. Interoperability is expected to generate substantial gains in quality and efficiency by reducing redundant care2 and improving care coordination through better frontline clinician access to information.3 It is also expected to be a key enabler of population-based payment and care delivery reform models through data aggregation4 and information technology (IT)–enabled performance measurement.5 In response, both the public6,7 and private sector8 are devoting substantial resources to increase interoperability by enhancing technical capabilities, as well as by addressing governance, financial, and policy issues.

In order to track progress and inform policy efforts, it is critical to assess where we stand today.9 Prior research has tracked EHR adoption over time and found that hospital characteristics, such as size, location, and ownership, are associated with adoption.1 A related set of studies have examined hospital characteristics associated with engaging in specific forms of electronic health information sharing; for example, private nonprofit hospitals and hospitals that were part of a healthcare system were more likely to participate in a community or Regional Health Information Organization (RHIO).10 A key difference between the 2 literatures is that the former uses a functionality-based, technology-agnostic definition of EHRs to assess adoption patterns,1,11 whereas the latter has lacked such a definition. We therefore took advantage of the recent effort by the Office of the National Coordinator for Health IT (ONC) to create a similar functionality-based, technology-agnostic definition of interoperability11,12 in order to begin to measure and track interoperability in a consistent and comparable way over time.

The definition includes 4 key domains: find, send, receive, and integrate,13 reflecting the fact that interoperability is comprised of multiple processes. Finding information involves the ability to query for patient data from outside institutions, and is a critical capability for unplanned care, such as emergency department visits. Sending and receiving can enable providers to exchange patient information during planned care transitions, such as referrals or following hospital discharge. Integrating patient information is the key capability that distinguishes interoperability from health information exchange (HIE); interoperability requires both that information is shared electronically and that no special effort on behalf of the user is needed to integrate that information into the provider’s EHR.14 Taken together, these 4 domains capture the core components of interoperability required for varied use cases in which provider organizations need to share information electronically.

Using these 4 domains as a framework, we sought to capture a current picture of interoperability in US hospitals, assess how interoperability varies by hospital characteristics—including health IT infrastructure, payment reform participation, and other demographics— and examine whether interoperability is associated with electronic availability of information from outside organizations at the point of care. We used data from the 2014 American Hospital Association (AHA) Annual Survey of Hospitals – IT Supplement  that included new questions on these capabilities. Our study is therefore the first to our knowledge to use this new functionality-based definition of interoperability, and offers a set of benchmark measures against which future progress can be assessed. This is critical to inform the wide array of efforts currently underway to ensure that disparate EHRs can provide clinicians access to complete patient information.


Data and Sample

Our study relied on data from 3 sources. We used data from the 2014 AHA IT Supplement to capture hospital engagement in the 4 domains of interoperability along with other measures of hospital characteristics.15 This survey is sent annually to the CEO of every hospital in the United States, and he or she is asked to complete it or delegate completion to a knowledgeable person in the organization. The 2014 AHA IT Supplement was fielded between November 2014 and February 2015, was sent to 6377 hospitals, and received 3307 responses.

Our second source of data was the 2014 AHA Annual Survey, fielded in the same manner as the 2014 AHA IT Supplement Survey, which we used to create additional measures of hospital characteristics.15 Finally, we used Stage 2 Meaningful Use attestation data from CMS’ 2015 Medicare Electronic Health Record Incentive Program Eligible Professionals Public Use File, which allowed us to measure the density of potential ambulatory partners with electronic exchange capabilities in each hospital’s market.16 Our primary analytic sample included all hospitals that responded to the 2014 AHA IT Supplement, for a total of 3307 hospitals. Although previous studies examining national health IT adoption and Meaningful Use engagement have typically limited the sample to nonfederal, general acute care hospitals, we decided to include federal and specialty hospitals as these hospitals deliver care that would benefit from engagement in interoperability.

Measures of Interoperability

We created 4 dichotomous measures to capture whether or not each hospital was engaged in each of the 4 interoperability domains. We also created variables to capture all the possible combinations of engagement in the 4 domains (eg, send only, send and receive only).

Finding. We defined finding data using the question, “Do providers at your hospital query electronically for patients’ health information (eg, medications, outside encounters) from sources outside your organization or hospital system?” We considered hospitals that responded “yes” as finding (querying) data.

Sending and receiving. We defined sending and receiving data using questions that asked, “When a patient transitions to another care setting or organization outside your hospital system, how does your hospital routinely send and/or receive a summary of care record?” For sending, providers who responded “yes” to 1 or more of the following options—“secure messaging using EHR (via direct or other secure protocol),” “provider portal,” or “via health information exchange organization or other third party”—were considered to be electronically sending data. The question offered the same options for “receive” and so we created an equivalent variable (eAppendix Table A [eAppendices available at]).

Integrating. We measured integrating data using responses to the question, “Does your EHR integrate any type of clinical information received electronically (not eFax) from providers or sources outside your hospital system/organization without the need for manual entry? This could be done using software to convert scanned documents into indexed, discrete data that can be integrated into EHR.” We considered respondents who answered “yes, routinely” or “yes, but not routinely” as integrating data.

Availability of Information From Outside Organizations

We used a new question on the 2014 AHA IT Supplement to create a dichotomous measure of whether providers in the hospital routinely had clinical information electronically available from outside providers or sources when needed. The question asked, “Do providers at your hospital routinely have necessary clinical information available electronically from outside providers or sources when treating a patient who was seen by another healthcare provider/setting?” We classified “yes” responses as providers had the clinical information they needed for patients who had been seen at outside providers.

Hospital Characteristics

We selected hospital characteristics, which fall into 3 categories—IT, organizational, and exchange partners—that we expected would be associated with engagement in interoperability domains. Our selection was based on prior studies examining characteristics associated with EHR adoption and participation in health information exchange (HIE) (eAppendix Table B).1,10,17

Our IT characteristics included EHR adoption status,11 participation in an RHIO,18 having a third-party HIE vendor, having their EHR vendor serve as their HIE vendor, and having primarily 1 EHR vendor. For organizational characteristics, we examined hospital size, teaching status, geographic location type, system membership, hospital ownership, specialty type, and payment reform participation.19,20 Finally, in order to evaluate the impact of available exchange partner density, we created 2 measures to capture potential exchange partners (eAppendix Table C).21

Analytic Models

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