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Getting From Here to There: Health IT Needs for Population Health
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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.
In addition, we focused on hospital characteristics and only included 2 market-level measures related to exchange partner density. Prior work suggests that market forces play an important role in hospitals’ decisions to pursue interoperability,10,28 and this points to the need for additional research focused on examining these dynamics. Finally, our cross-sectional data captures a recent snapshot of interoperability and, although we speculate on some potential causal relationships, we cannot empirically assess them. It is important to note that our study reports slightly different results than previous ONC publications on US hospital interoperability engagement using the same data source.9 This discrepancy is due to our decision to include all hospitals in our results rather than only nonfederal, acute care hospitals. Although federal and specialty hospitals are not subject to the same policy environment as general hospitals—because the same patients may receive care at both types of hospitals—we felt it was important to include all hospitals in our measures.



Our findings have important policy implications. First, the measures of interoperability engagement that we examine in this study are part of the final set of measures that will be used to report to Congress to assess the extent to which interoperability is occurring on a widespread basis by 2018, as mandated by the Medicare Access and CHIP Reauthorization Act (MACRA) rule.29 Our findings lend credibility to these measures, given that we found they are strongly associated with increased availability of outside information. However, given that we also found a majority of hospitals do not engage in all 4 domains, there is a need for ongoing policy efforts to increase such engagement. Efforts to enable interoperability should not solely focus on sending information during care transitions—which is heavily emphasized in current Meaningful Use criteria—but also on finding, receiving, and integrating information. MACRA takes a step in this direction by encouraging providers to not only send, but also receive and incorporate, patient care records eletronically.30 However, they would need to be expanded in at least 2 key ways: the MACRA rules only apply to eligible providers, not hospitals, and they set a fairly low bar with regard to integrating information. Progress in the integration domain would also likely be sped up by efforts to identify and implement the best available data standards that enable receiving and integrating data across systems. As a start, vendors representing 90% of the hospital EHR market have committed to implement “national interoperability standards and best practices”31 that are part of the Shared Nationwide Interoperability Roadmap.13

Although delivery and payment reform should also drive hospitals toward greater engagement in interoperability, our findings suggest that these forces have not yet fully matured.  Specifically, while medical home model participation was associated with engaging in all 4 domains of interoperability, participation in only ACOs was not. Reform efforts could become more forceful levers if interoperability-sensitive outcome measures were developed and then tied to participation and payment.4,32 Regardless, as delivery and payment reform accelerate, hospitals will need cost-effective options to seamlessly exchange information. Linking interoperability to various initiatives and funding sources, such as state innovation model funding, new Health Information Technology for Economic and Clinical Health match funding for Medicaid, and Medicaid managed care contracting, could help address remaining gaps across the country with regards to interoperability engagement.33


We used recent survey data from US hospitals to assess the current state of interoperability using a functionality-based definition comprised of 4 core domains. Only one-fifth of hospitals engaged in all 4 domains of interoperability; hospitals possessing key health IT capabilities were more likely to engage in all 4. Organizational characteristics associated with interoperability differed from those associated with hospital EHR adoption, suggesting a unique set of factors affecting hospital interoperability. Perhaps most importantly, engaging in finding, receiving, and integrating information was strongly associated with routine availability of necessary clinical information from outside providers. This underscores the need to speed progress toward ensuring that all hospitals engage in these core domains of interoperability. Policy interventions, including the expansion of value-based delivery reform like medical homes and new interoperability incentives contained in MACRA, may speed hospital engagement in interoperability and the improved outcomes that are expected to follow. 

Author Affiliations: University of Michigan (AJH, JA-M), Ann Arbor, MI; Office of the National Coordinator for Health Information Technology (VP, DC), Washington, DC.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DC, AJH, JA-M, VP); acquisition of data (DC, JA-M, VP); analysis and interpretation of data (DC, AJH, JA-M, VP); drafting of the manuscript (DC, AJH, JA-M, VP); critical revision of the manuscript for important intellectual content (DC, AJH, JA-M, VP); statistical analysis (AJH); and supervision (JA-M).

Address Correspondence to: A. Jay Holmgren, BA, 105 S State St, Ann Arbor, MI 48103. E-mail:

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