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The American Journal of Managed Care December 2016
Getting From Here to There: Health IT Needs for Population Health
Joshua R. Vest, PhD, MPH; Christopher A. Harle, PhD; Titus Schleyer, DMD, PhD; Brian E. Dixon, MPA, PhD, FHIMSS; Shaun J. Grannis, MD, MS, FAAFP, FACMI; Paul K. Halverson, DrPH, FACHE; and Nir Menache
The Health Information Technology Special Issue: Current Trends and Future Directions
Joshua R. Vest, PhD, MPH
How Health Plans Promote Health IT to Improve Behavioral Health Care
Amity E. Quinn, PhD; Sharon Reif, PhD; Brooke Evans, MA, MSW; Timothy B. Creedon, MA; Maureen T. Stewart, PhD; Deborah W. Garnick, ScD; and Constance M. Horgan, ScD
Data-Driven Clinical and Cost Pathways for Chronic Care Delivery
Yiye Zhang, PhD, and Rema Padman, PhD
Accountable Care Organization Hospitals Differ in Health IT Capabilities
Daniel M. Walker, PhD, MPH; Arthur M. Mora, PhD, MHA; and Ann Scheck McAlearney, ScD, MS
Building Health IT Capacity to Improve HIV Infection Health Outcomes
Hannah Rettler, MPH; R. Monina Klevens, DDS, MPH; Gillian Haney, MPH; Liisa Randall, PhD; Alfred DeMaria, MD; and Johanna Goderre, MPH
Telemedicine and the Sharing Economy: The "Uber" for Healthcare
Brian J. Miller, MD, MBA, MPH; Derek W. Moore, JD; and Chester W. Schmidt, Jr, MD
Assessing Electronic Health Record Implementation Challenges Using Item Response Theory
Kitty S. Chan, PhD; Hadi Kharrazi, MD, PhD; Megha A. Parikh, MS; and Eric W. Ford, PhD, MPH
Payer—Provider Patient Registry Utilized in a Behavioral Health Home
Michele Mesiano, MSW; Meghna Parthasarathy, MS; Shari L. Hutchison, MS, PMP; David Salai, BS; Suzanne Daub, LCSW; Mary Doyle, MHIS; and James M. Schuster, MD, MBA
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US Hospital Engagement in Core Domains of Interoperability
A. Jay Holmgren, BA; Vaishali Patel, PhD; Dustin Charles, MPH; and Julia Adler-Milstein, PhD

US Hospital Engagement in Core Domains of Interoperability

A. Jay Holmgren, BA; Vaishali Patel, PhD; Dustin Charles, MPH; and Julia Adler-Milstein, PhD
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.
Finally, we examined the predictors of information availability from outside organizations. Our explanatory variables in the logistic regression model were the 4 interoperability domain variables: find, send, receive, and integrate. We included send as a logic check, and did not expect that sending data would be significantly associated with clinical information availability. Additional explanatory variables included the hospital characteristics from the previous model. We removed the variables that we did not expect would be related to information availability: having a third-party HIE vendor, having their EHR vendor as their HIE vendor, and using primarily 1 EHR vendor; these measures are key enablers of interoperability engagement, but not likely related to clinical information availability. The model included the same weights, and was run twice, with and without exchange partner measures. Finally, to assess the potential for synergistic effects from engaging in multiple interoperability domains, we re-ran the model with all possible interaction terms between find, send, receive, and integrate.


Sample Characteristics

Over half of the hospitals had at least a “basic” (defined as an EHR with a set of 10 functionalities implemented in at least 1 unit of the hospital) EHR system (60%), while “comprehensive” (defined as an EHR with a larger set of functionalities implemented across all units of the hospital) EHR systems were less common (29%). Nearly half of the hospitals were participating in a RHIO (49%), and many hospitals had a third-party HIE vendor (80%). The majority of hospitals in our sample were small (53%) or medium-sized (40%); most hospitals were located in an urban setting (64%) and nearly half were privately owned, nonprofit (49%) (eAppendix Table D). Almost one-fifth of sample hospitals participated in an ACO (17%) and a medical home (17%), with only 8% participating in both. In HRR-level markets with at least 10 respondents, 68% of hospitals in the market, on average, engaged in sending information electronically. Similarly, the mean number of “eligible provider” exchange partners per hospital by HRR was 1.45 across all hospitals in the sample (eAppendix Table C). 

Interoperability in US Hospitals

Twenty-one percent of US hospitals engaged in all 4 interoperability domains (Table 1 and eAppendix Figure). An additional 17% of hospitals engaged in some combination of the 3 domains—the most common of which was send, receive, and integrate data (8% of total respondents). Another 20% of hospitals engaged in 2 domains of interoperability, with the most common combination being send and receive (10% of total respondents). Seventeen percent of hospitals engaged in 1 of the domains of interoperability, and the most common single domain was send (8% of total respondents). The remaining one-fourth of hospitals did not engage in any of the 4 domains.

Hospital Characteristics Associated With Engagement in All 4 Interoperability Domains

Several characteristics were significantly associated with hospital engagement in all 4 domains of interoperability (Table 2). Hospitals with a basic or comprehensive EHR (odds ratio [OR], 3.53 and 5.04, respectively; P <.01) were more likely to be engaged in all 4 domains, as were hospitals participating in an RHIO (OR, 4.29; P <.01). Hospitals with a third-party HIE vendor (OR, 2.32; P <.01), hospitals using their EHR vendor as their HIE vendor (OR, 2.15; P <.01), and hospitals using only 1 EHR vendor (OR, 2.04; P <.01) were also more likely to be engaged in all 4 domains.

Among the organizational characteristics, medium-sized hospitals (OR, 1.51; P <.01) and hospitals that are part of a system (OR, 1.88; P <.01) were more likely to engage in all 4 interoperability domains, as were hospitals participating in a medical home model18 (OR, 1.77; P <.01) or both an accountable care organization (ACO) and a medical home model (OR, 1.78; P = .02).

When we examined the exchange partner density variables, neither the proportion of hospitals in the HRR that electronically send information nor the number of eligible professionals in the HRR that had attested to Stage 2 Meaningful Use, were related to engagement in all 4 interoperability domains (eAppendix Table E).

Characteristics Associated With Clinical Data Availability

 Just over one-third of sample hospitals reported having clinical information available from outside providers when necessary (36%) (eAppendix Table D). Find (OR, 5.51; P <.01), receive (OR, 2.56; P <.01), and integrate (OR, 2.53; P <.01) information were associated with the availability of information from outside providers. As expected, send was not associated with clinical information availability (OR, 0.98; P = .92) (Table 3).

Other statistically significant characteristics associated with electronic availability of information from outside providers included hospitals with a basic or comprehensive EHR system (OR, 1.47 and 2.02, respectively; P <.01), and hospitals owned by the federal government compared with privately owned nonprofit hospitals (OR, 2.29; P = .03). Neither exchange partner variable was related (eAppendix Table F). In our fully interacted model, hospitals that engaged in all 4 interoperability domains had significantly greater odds of electronic clinical information availability from outside sources (OR, 38.32; P <.01) (eAppendix Table G).


There is widespread agreement that interoperability across EHR systems is needed to ensure that providers have ready access to health information about their patients. Our results offer a baseline measure for the state of interoperability in US hospitals and suggest that continued efforts are needed both to increase interoperability and for data from outside providers to be routinely available. Key enablers of interoperability appear to center on certain health IT infrastructure and HIE services. Having a basic or comprehensive EHR ensures that there is a core set of patient information captured electronically, such as problem and medication lists, which are valuable both to share with outside providers during care transitions and update with information received from outside providers.1 Encouragingly, all forms of technology solutions were positively associated—ranging from RHIO to third-party HIE vendors to EHR vendors providing HIE solutions. This suggests the possibility that hospitals are pursuing varied approaches to connectivity and that the policy strategy of letting the market develop different approaches to exchange may be allowing hospitals to choose the approach that works best for them.

We were somewhat surprised to find that medical home model participation was significantly associated with engaging in all 4 interoperability domains, and ACO participation alone was not. This finding could be explained by the fact that care coordination activities are core requirements of most medical home programs, and hospitals therefore have to invest in some level of sending, receiving, and integrating information. The National Committee for Quality Assurance specifically recommends that medical homes invest in interoperability and HIE capabilities for the purposes of care coordination and ensuring high-quality care.20 We also found that being a member of a system was associated with engagement in interoperability. We suspect that hospitals that are part of a system are more likely to share patients with other members of the system, making interoperability more valuable, as well as have established relationships and policies with other members of the system that make exchange easier.

Many of the characteristics that we hypothesized would be related to interoperability engagement were not, including several that have historically been associated with EHR adoption. Large hospitals, teaching hospitals, and urban hospitals were not more likely to be engaged, despite being more likely to have comprehensive EHR systems.1 This suggests that a different set of factors influence interoperability engagement compared with EHR adoption.11 For example, large hospitals may have been able to leverage their greater resources in EHR adoption, but the increased complexity that comes with being a larger facility may make engaging in interoperability more difficult. Although there is a growing understanding of the barriers to interoperability,9 our findings suggest the need for further exploration across different hospital settings.

Our findings related to predictors of clinical information availability from outside providers also yielded interesting insights. That find and receive were both associated with clinical information availability reinforces the notion that different types of information access are needed for different clinical scenarios. Whereas finding is needed in emergency care or when the provider does not know where the patient has previously received care,22 receiving data supports planned care transitions.23 Integrating appears to offer additional value, likely by decreasing the workload for clinicians to view and incorporate information into workflow and decision making. A recent systematic review of the HIE literature found that the key barriers reported from a provider standpoint were workflow disruptions and technical trouble with the interface.24 By integrating clinical information directly into hospital EHRs, clinicians are more likely to have access to outside information.25,26


Our findings should be interpreted with some key limitations in mind. First, we used self-reported survey data and were not able to verify the accuracy of responses. However, data from the AHA IT Supplement are widely used to track hospital EHR adoption and have been validated against other sources.27 Our measures of engagement in the 4 interoperability domains and measure of availability of clinical information from outside providers are dichotomous, thus limiting our ability to measure the breadth of engagement and the degree to which information are available. Although survey questions related to the domains of send and receive refer specifically to summary of care records,11 the questions related to the domains of find and integrate refer to any clinical patient information. Another measurement challenge is the fact that respondents could have differentially interpreted what it meant to engage in a domain “routinely.”

Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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